A Clinical Guide To Othodontics

PRACTICE
IN BRIEF
This series of articles is designed to aid in the orthodontic evaluation of patients

Not every malocclusion needs orthodontic treatment
Not every patient is suitable for treatment
Understanding the treatment benefit for the patient is important
GDPs have an important role to play in assessing the need for orthodontic treatment
VERIFIABLE
CPD PAPER
Orthodontics. Part 1: Who needs orthodontics?

D. Roberts-Harry1 and J. Sandy2
There are various reasons for offering patients orthodontic treatment. Some of these include
improved aesthetics, occlusal function and the long-term dental health.
ORTHODONTICS
1. Who needs
orthodontics?
2. Patient assessment and
examination I
examination II
4. Treatment planning
5. Appliance choices
6. Risks in orthodontic
treatment
7. Fact and fantasy in
orthodontics
8. Extractions in
orthodontics
9. Anchorage control and
distal movement
10. Impacted teeth
11. Orthodontic tooth
movement
12. Combined orthodontic
treatment
Orthodontics comes from the Greek words

orthos meaning normal, correct, or straight
and dontos meaning teeth. Orthodontics is
concerned with correcting or improving the
position of teeth and correcting any malocclusion. What then do we mean by occlusion and
malocclusion? Surprisingly the answer is not
straightforward. There have been various
attempts to describe occlusion using terms such
as ideal, anatomic (based on tooth morphology), average, aesthetic, adequate, normally
functioning and occlusion unlikely to impair
dental health.
With these different definitions of what constitutes malocclusion, there is, not surprisingly a
degree of confusion as to what should be treated
and what should not. Although some tooth positions can produce tooth and soft tissue trauma, it
is important to remember that malocclusion is
not a disease but simply a variation in the normal position of teeth. Essentially, there are three
principal reasons for carrying out orthodontic
treatment:
1. To improve dento facial appearance
2. To correct the occlusal function of the teeth
Department, Leeds Dental Institute,

Clarendon Way, Leeds LS2 9LU; 2Professor
in Orthodontics, Division of Child Dental
Health, University of Bristol Dental School,
Lower Maudlin Street, Bristol BS1 2LY
*Correspondence to: D. Roberts-Harry
E-mail: robertsharry@btinternet.com
Fig. 1a A child with a Class II

division 1 malocclusion and
very poor aesthetic appearance
1*Consultant Orthodontist, Orthodontic
Fig. 1b The same child as

in Fig. 1a
Refereed Paper
doi:10.1038/sj.bdj.4810592
British Dental Journal 2003; 195:
433437
BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 2003
433
Fig. 2a Same child as in

Fig. 1 after orthodontic
treatment
Table 1 Features children most dislike or are teased

about (Shaw et al.1)
Feature
Teeth
Clothes
Ears
Weight
Brace
Nose
Height
Fig. 3 This patient

has a severe
anterior open bite
with contact only
on the molars
Fig. 4 Class II
Division 1 with an
increased overjet.
The anterior teeth
are at risk of
potential trauma
with an overjet of
10 mm or greater
434
Disliked appearance
or teased (%)
60.7
53.8
51.7
41.5
33.3
29.3
25.3
PRACTICE
Fig. 2b Occlusion of the same

patient as in Fig. 2a, there has
been a significant
improvement in the buccal
segment relation and overjet
compared with the initial
presentation in Fig. 1b
3. To eliminate occlusion that could damage the

long-term health of the teeth and periodontium
DENTO FACIAL APPEARANCE

Improving the appearance of the teeth is without
question the main reason why most orthodontic
treatment is undertaken. Although it might be
tempting to dismiss this as a trivial need, there is
little doubt that a poor dental appearance can
have a profound psychosocial effect on children.
Figure 1 illustrates such a case with a child who
has a substantial aesthetic need for treatment.
The case is shown before (Fig. 1a, b) and after
(Fig 2a, b) orthodontic treatment. Few would
question that there has been an improvement in
both the dental and facial appearance of this
child. Indeed, orthodontic treatment can have a
beneficial psychosocial effect. For example
Shaw et al.1 found that children were teased
more about their teeth than anything else, such
as the clothes they wear or their weight and
height (Table 1).
OCCLUSAL FUNCTION
Teeth, which do not occlude properly, can make
eating difficult and may predispose to temporomandibular joint (TMJ) dysfunction. However,
the association with TMJ dysfunction and malocclusion is a controversial subject and will be
discussed in more detail in a later section. Individuals who have poor occlusion, such as shown
in Figure 3, may find it difficult and embarrassing to eat because they cannot bite through food
using their incisors. They can only chew food
using their posterior teeth.
DENTAL HEALTH
Surprisingly there is no strong association
between dental irregularity and dental caries or
periodontal disease. It seems that dietary factors
are much more important than the alignment of
the teeth in the aetiology of caries. Although
straight teeth may be easier to clean than
crooked ones, patient motivation and dental
PRACTICE
hygiene seems to be the overriding factor in preventing gingivitis and periodontitis. That said,
few of the studies that have investigated the link
between crowding and periodontal disease have
been longitudinal, over a long term and included
older adults. It would appear that aligned teeth
confer no benefit to those who clean their teeth
well because they can keep their teeth clean
regardless of any irregularity. Similarly, alignment will not help bad brushers. If there is poor
tooth brushing, periodontal diseases will develop no matter how straight the teeth are. However, having straight teeth may help moderate
brushers, although there is no firm evidence to
support or refute this statement. This is an area
that requires further study.
Some malocclusions may damage both the
teeth and soft tissues if they are left untreated. It is
well known that the more prominent the upper
incisors are the more prone they are to trauma2,3
(Table 2).
When the overjet is 9 mm or more the risk of
damaging the upper incisors increases to over
40%. Reducing a large overjet is not only beneficial from an aesthetic point of view but minimises the risk of trauma and long-term complications to the dentition. Fig. 4 shows a child
with a large overjet and it is not difficult to
imagine the likely dental trauma that would
result if he or she fell over.
Table 2 Relation between size of overjet and

prevalence of traumatised anterior teeth
Overjet (mm)
Incidence %
5
9
>9
22
24
44
Certain other occlusal relationships are also

liable to cause long-term problems. Figure 5a
and b show a case where there is an anterior
cross-bite with an associated mandibular displacement in a 60-year-old man. The constant
attrition of the lower incisors against the upper
when the patient bites together, have produced
some substantial wear. If allowed to continue
then the long-term prognosis for these teeth is
extremely poor. In order to preserve the teeth,
the patient accepted fixed appliance treatment
that eliminated the cross bite and helped prevent
further wear Figure 5c and d.
Another example of problems caused by an
anterior cross bite is shown in Figure 6. A traumatic anterior occlusion produced a displacing
force on the lower incisors with apical migration
of the gingival attachment as a consequence. Provided this situation is remedied early (Fig. 7) the
soft tissue damage stops and as the rest of the
gingivae matures the situation often resolves
Fig. 5a Anterior crossbite in a 60-year-old man occluding

in the intercuspal position
Fig. 5b Shows the retruded contact position of the patient.

To reach full intercuspation the mandible displaces forward
and this movement is probably associated with the wear on
the incisors
Fig. 5c The patient in fixed appliances in order to

correct the displacement and the position of his upper
anterior teeth
Fig. 5d After correction and space reorganisation the patient

is wearing a prosthesis to replace the missing lateral incisors
435
PRACTICE
vidual will receive from this will depend on the
severity of the presenting malocclusion as well as
the patients own perception of the problem.
Some individuals can have a marked degree of
dento-facial deformity and be unconcerned with
their appearance. Although a practitioner may
suggest treatment for such an individual,
patients should not be talked into treatment and
must be left to make the final decision themselves. Mild malocclusions should be treated with
caution. Not only will the net improvement in the
appearance of the teeth be small, but also as
nearly all teeth move to some degree after orthodontic treatment the risk of relapse in these cases
is high. Whilst minor movements after the correction of severe malocclusions will still produce
a substantial net overall improvement for the
patients, the same is not true of minor problems.
Many practitioners will have encountered the
parent who can spot a 5-degree rotation of an
upper lateral incisor from fifty metres and is convinced this will be the social death of their child.
Regardless of how insistent the parent or child is,
the practitioner should approach such problems
Fig. 6 A traumatic
anterior occlusion
is displacing the
lower right central
incisor labially and
there is an
associated
dehiscence
Fig. 7 The same

patient as in Fig. 6,
but the cross bite
has been corrected
with a removable
appliance and
there has been
an improvement
in the gingival
condition
Table 3 Index of Treatment Need

Dental health component
spontaneously and no long-term problems usually develop.

Deep overbites can occasionally cause stripping of the soft tissues as shown in Figure 8a
and b. This is a case where there is little aesthetic need for treatment but because of the
deep overbite there is substantial damage to
the soft tissues. Clearly if this is allowed to
continue there is a risk of early loss of the
lower incisors that would produce a difficult
restorative problem.
WHO SHOULD BE TREATED?

Dental irregularity alone is not an indication for
treatment. Most orthodontic treatment is carried
out for aesthetic reasons and the benefit an indi-
Fig. 8a This malocclusion has an extremely deep bite which

can be associated with potential periodontal problems
436
1
2
3
4
5
Aesthetic component
1
2
3
4
5
6
7
8
9
10
Treatment need
No need
Little need
Moderate need
Great need
Very great need
Treatment need
Little need
Moderate need
Great need
Fig. 8b The same patient as in Fig. 8a, but not in

occlusion. The deep bite has resulted in labial stripping
of the periodontium on the lower right central incisor
PRACTICE
with care and only carry out the treatment if it is in
the best interests of the patient. It is essential that
the patient and parent are fully aware of the limitations of treatment and that long term, ie permanent retention is currently the only way to ensure
long-term alignment of the teeth.
In order to assess the need for orthodontic
treatment, various indices have been developed.
The one used most commonly in the United Kingdom is the Index of Orthodontic Treatment Need
(IOTN).4 This index attempts to rank malocclusion, in order, from worst to best. It comprises two
parts, an aesthetic component and a dental health
component (Table 3). The aesthetic component
consists of a series of ten photographs ranging
from most to least attractive. The idea is to match
the patients malocclusion as closely as possible
with one of the photographs. It is unlikely that a
perfect match will be found but the practitioner
should use his or her best guess to match to the
nearest equivalent photograph. The dental health
component consists of a series of occlusal traits
that could affect the long-term dental health of
the teeth. Various features are graded from 15
(least severe worst). The worst feature of the
presenting malocclusion is matched to the list and
given the appropriate score.
Many hospital orthodontic services will not
accept patients in categories 13 of the dental
health component or grade 6 or less of the aesthetic component of the IOTN unless they are suitable for undergraduate teaching purposes.
Whilst the IOTN is a useful guide in prioritising
treatment and determining treatment need it
Fig. 9 The Index of

Treatment Need
for this patient
is 2. Although this
is low, the level of
expertise required
to treat it is high
takes no account of the degree of treatment difficulty. For example, class II division 2 malocclusions are notoriously difficult to treat yet they
might have a low IOTN. Figure 9 illustrates such a
case. The IOTN of this patient is only 2 but it is a
difficult case to manage and treatment requires
a high level of expertise.
1.
2.
3.
4.
Shaw W C, Meek S C, Jones D S. Nicknames, teasing,

harassment and the salience of dental features among school
children. Br J Orthod 1980; 7: 75-80.
Office of Population Censuses and Surveys (1994). Childrens
dental health in the United Kingdom 1993. London: HMSO
0116916079.
Office of Population Censuses and Surveys (1985). Childrens
dental health in the United Kingdom 1983. London: HMSO
0116911360.
Brook P, Shaw W C. The development of an index of
orthodontic treatment priority. Eur J Orthod 1989; 11:
309-320.
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437
PRACTICE
IN BRIEF
Careful patient assessment is the most important part of treatment

The extra-oral examination is conducted first
The skeletal relationship must be assessed three-dimensionally
The teeth lie in a position of soft tissue balance
Habits such as thumb sucking can induce a malocclusion
There is no proven association between TMJ dysfunction and orthodontics
2
VERIFIABLE
CPD PAPER
Orthodontics. Part 2: Patient assessment and

examination I
The patient assessment forms the essential basis of orthodontic treatment. This is divided
into an extra-oral and intra-oral examination. The extra-oral examination is carried out first
as this can fundamentally influence the treatment options. The skeletal pattern, soft tissue
form and the presence or absence of habits must all be taken into account.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment

Refereed Paper
doi:10.1038/sj.bdj.4810659
489493
The most important part of orthodontic treatment is the patient assessment. Once a particular treatment strategy is started subsequent
changes are often difficult. If it is decided that
extractions are needed and since the process is
irreversible, they must be carefully considered
in the treatment planning process. Inappropriate orthodontic treatment can produce adverse
results and it is essential that full examination
of skeletal form, soft tissue relationships and
occlusal features are performed prior to undertaking treatment. It is sensible to carry out the
assessment in a logical order so that none of the
steps are missed. A simple assessment should
include the following:
Medical history
Patients complaint
Extra-oral examination
Intra-oral examination
Radiographs
Orthodontic indices
Justification for treatment
Treatment aims
Treatment plan
This section concentrates on the extra- and

intra-oral examination of the patient.
EXTRA-ORAL EXAMINATION
It is helpful to follow the examination sequence
outlined:
Skeletal pattern
Soft tissues
Temporomandibular joint examination
BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 2003
Skeletal pattern
Patients are three-dimensional and therefore the
skeletal pattern must be assessed in anteriorposterior (A-P), vertical and transverse relationships. Although the soft tissues can tip the
crowns of the teeth the skeletal pattern fundamentally determines their apical root position.
The relative size of the mandible and maxilla to
each other will determine the skeletal pattern.
The smaller the mandible or the larger the maxilla the more the patient will be Class II. Conversely with a bigger mandible or smaller maxilla the
patient will be more Class III. The bigger the size
discrepancy between the maxilla and mandible,
the more difficult treatment becomes and the
less likely it is that orthodontics alone will be
able to correct the malocclusion. Although some
orthodontic appliances have a small orthopaedic
effect, treatment is generally most easily accomplished on patients with a normal skeletal pattern and a normal relationship of the maxilla to
the mandible.
Anterior-posterior (AP)
Although precise skeletal relationships can be
determined using a lateral cephalostat radiograph, many practices do not have this facility
and it is important to be able to assess the skeletal relationships clinically.
To assess the AP skeletal pattern the patient
has to be postured carefully with the head in a
neutral horizontal position (Frankfort Plane horizontal to the floor). Different head postures can
mask the true relationship. If the head is tipped
back the chin tends to come further forward and
makes the patient appear to be more Class III.
489
PRACTICE
A
Fig. 1
A tracing of
a lateral cephalostat
radiograph identifying soft
tissue points A and B
490
Fig. 2 Shows a patient with a skeletal III pattern

where a tracing of the lateral cephalostat
radiograph has been superimposed on the
photograph. The soft tissue masks to some
extent a significant skeletal III pattern
underlying skeletal pattern. Obviously the soft

tissue thickness may vary and mask the AP
skeletal pattern to some degree but generally
the thickness of the upper and lower lips is similar. The underlying skeletal pattern is therefore
often reflected in the soft tissue pattern. The
more severe the skeletal pattern is the more difficult treatment of the resulting malocclusion
becomes. Figure 3a and b, shows an adult with
an obvious skeletal III pattern and a malocclu-
Conversely, if the head is tipped down the chin

moves back and the patient appears to be more
Class II. Sit the patient upright in the dental
chair and ask them to occlude gently on their
posterior teeth. Ask them to gaze at a distant
point; this will usually bring them into a fairly
neutral horizontal head position. Look at the
patient in profile and identify the most concave points on the soft tissue profile of the
upper and lower lips (Fig. 1).
The point on the upper lip is called soft tissue A point and on the lower lip soft tissue B
point. In a patient with a class I skeletal pattern
B point is situated approximately 1 mm behind
A point. The further back B point is, the more
the pattern is skeletal II and the more anterior,
the more skeletal III it becomes. Figure 2 shows
a patient with a skeletal III pattern where the
outline of the hard tissues has been superimposed on the photograph. This demonstrates
that although we are examining the soft tissue
outline this also gives an indication of the
Fig. 3a Profile of an
adult who has an
obvious skeletal III
pattern
Fig. 3b Malocclusions of the same

patient in Figure 3a. The patient
has a Class III malocclusion
which is beyond the scope of
orthodontics alone
PRACTICE
sion that is clearly beyond the scope of orthodontic treatment alone.
Vertical dimension
This dimension gives some indication of the
degree of overbite. The vertical dimension is
usually measured in terms of facial height and
the shorter the anterior facial height the more
likely it is that the patient will have a deep overbite. Conversely the longer the facial height the
more the patient is likely to have an anterior
open bite. Deep overbites associated with a short
anterior facial height and open bites with long
face heights are difficult to correct with orthodontics alone. The greater the skeletal difference
the more likely it is that the patient will need a
combination of orthodontics and orthognathic
surgery to correct the occlusion and the underlying skeletal discrepancy.
50%
50%
Fig. 4
Assessment of
facial proportions.
The upper and
lower anterior
face heights
should be
approximately
equal
Fig. 5 Profile of a
patient with a
much reduced
lower anterior
facial height
There are various ways of measuring the

vertical dimension, one of the most common is
to measure the Frankfort Mandibular Planes
Angle. This is not a very easy clinical angle to
measure and the problem is compounded by
the fact that not many clinicians can identify
the Frankfort Plane correctly. A more practical
way of assessing this is simply to measure the
vertical dimension as indicated in Figure 4.
The lower anterior facial height is the distance from the base of the chin to the base of
the nose. The upper anterior facial height is
the distance from the base of the nose to a
point roughly between the eyebrows. These
dimensions can be measured with a ruler
although the index finger and thumb will do
almost as well. The lower and upper facial
heights are usually equal. If the lower anterior
facial height is reduced, as illustrated in Figure 5, this can result in a deep overbite that
can be difficult to correct (Fig. 6). Conversely,
if the lower anterior facial height is greater
Fig. 6 Occlusion of the patient

shown in Figure 5. The reduced
lower anterior face height is
often associated with a deep
bite as shown
than 50% this can produce an anterior openbite (Fig. 7).
Transverse dimension
To assess this dimension, look at the patient
head-on and assess whether there is any asym-
Fig. 7 Anterior
open bites are
often associated
with an increase in
lower anterior face
height
491
PRACTICE
Fig. 8 A centre line

shift where the
lower centre line is
to the left
Fig. 9 Teeth are

in soft tissue balance
between the tongue and
the lips
Fig. 10 These diagrams show how partial reduction of the overjet does not allow the
lip to cover the upper incisors. The upper incisors are then quite likely to return to
their pre-treatment position
492
metry in the facial mid-line. If there appears to

be any mandibular asymmetry this may be
reflected in the position of the teeth as shown
in Fig. 8. If there is asymmetry it is important
to distinguish between false and true asymmetry. A false asymmetry arises when occlusal
interferences force the patient to displace the
mandible laterally producing a cross-bite in
the anterior or buccal region. If the displacement is eliminated then the mandible will
return to a centric position. A true asymmetry
arises as a consequence of unequal facial
growth on the left or right side of the jaws. In
these cases elimination of any occlusal crossbites (which can be very difficult) is unlikely to
improve the facial asymmetry.
SOFT TISSUE EXAMINATION

The soft tissues comprise the lips, cheeks and
tongue and these guide the crowns of the teeth
into position as they erupt. Ultimately, the teeth
will lie in a position of soft tissue balance
between the tongue on one side and the lips and
cheeks on the other (Fig. 9).
In patients with a Class I incisor relationship the soft tissues rarely play an important
part unless there is an anterior open-bite. The
anterior open-bite may be caused by a digit
sucking habit, a large lower anterior facial
height, localised failure of eruption of the
teeth, proclination of the incisors or to an
endogenous tongue thrust. The latter cause is
very rare and is usually identified by a large
thrusting tongue that seems to permanently sit
between the upper and lower incisors. This
type of anterior open-bite is extremely difficult to correct. It is usually possible to reduce
it, but on completion of treatment the tongue
invariably pushes between the teeth and they
move apart once again.
An important aspect of lip position is seen
in patients with an increased overjet. If the
upper incisor prominence is reduced, stability
usually depends on the lower lip covering the
upper incisors in order to prevent the overjet
increasing post-treatment. Therefore, careful
examination of the position of the lower lip in
relation to the upper incisors is important. If
the lower lip does not cover the upper incisors
sufficiently after treatment, relapse of the
overjet may occur. Similarly, if the overjet is
to be reduced, full reduction is very important
in order to give the lip the best possible
chance of stabilising the incisors. Figure 10
illustrates the point; partial reduction of the
overjet does not allow the lip to cover the
upper incisors and they are likely to return to
their pre-treatment position.
Whilst many young children have incompetent lips, this is often just a normal stage of
development. As they pass through puberty, the
lip length increases relative to the size of the face
and the degree of lip competence gradually
improves (Fig. 11).1
Lip incompetence can be caused by either a
lack of lip tissue or an adverse skeletal pattern. If
PRACTICE
Overlap (mm)
5
-5
10
15
20
Age (years)
Fig. 11 Lip length is thought to increase as children pass through the pubertal growth
spurt. This will aid retention of overjet reduction
the skeletal pattern is unfavourable in either the

vertical or anterior-posterior position then even
with normal lip length the soft tissues are still
widely separated.
HABITS
Digit sucking is a well-known factor in producing anterior open-bite, proclined upper
incisors and buccal cross-bites. If the habit
ceases while the child is still growing then the
incisors are very likely to return to their normal position. However, once the teenage years
are passed and facial growth slows down,
spontaneous resolution becomes increasingly
unlikely. If the habit persists into adult life it
may be necessary to use appliance treatment to
correct the habit induced anterior open-bite.
Buccal cross-bite possibly produced by digit
sucking habits, rarely resolve spontaneously
on cessation of the habit because of occlusal
interferences. These buccal cross-bites often
need to be corrected with active appliance

treatment.
TEMPORO-MANDIBULAR JOINT PROBLEMS

A comprehensive review of the literature by
Luther2,3 failed to demonstrate any conclusive
association between TMJ dysfunction, malocclusion and orthodontic treatment. However, it
is important that the joints are palpated and
assessed for signs and symptoms of TMJ dysfunction. Patients who present with TMJ pain
seeking an orthodontic solution to correct the
problems should be treated with caution.
1.
2.
3.
Vig P S, Cohen A M. Vertical growth of the lips: a serial

cephalometric study. Am J Orthod 1979; 75: 405-415.
Luther F. Orthodontics and the tempromandibular joint:
where are we now? Part 1. Orthodontic treatment and
temporomandibular disorders. Angle Orthod 1998; 68:
305-318.
Luther F. Orthodontics and the temporomandibular joint:
where are we now? Part 2. Functional occlusion,
malocclusion, and TMD. Angle Orthod 1998; 68: 305-318.
493
PRACTICE
IN BRIEF
Careful patient assessment is the most important part of treatment

The intra-oral examination is conducted after the extra-oral assessment
The degree of occlusal discrepancy influences the treatment options
The dental health and patient motivation determine if appliance therapy can be used
3
VERIFIABLE
CPD PAPER
Orthodontics. Part 3: Patient assessment and

examination II
The intra-oral assessment examines the oral health, individual tooth positions and
inter-occlusal relationships. When this has been completed in conjunction with the
extra-oral examination, a treatment plan can then be formulated.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment

Refereed Paper
doi:10.1038/sj.bdj.4810724
563565
INTRA-ORAL EXAMINATION
There are various systems available to assess this
aspect but the following sequence is both practical and thorough:
Dental health
Lower arch
Upper arch
Teeth in occlusion
Radiographs
Dental health
Even individuals with severe malocclusions
should not have active orthodontic treatment in
the presence of dental disease. Orthodontic
appliances accumulate plaque and if the patient
has a poor diet and tooth brushing then irreversible damage can result as demonstrated in
Figure 1. Although the patient has straight teeth
there is considerable decalcification and it could
be argued is worse off as a consequence of treatment. Clearly this could have serious medicolegal complications, particularly if the clinician
fails to write in the notes that appropriate dental
health advice has been given
Decalcification around orthodontic appliances
is a recognised hazard and will occur in the presence of poor oral hygiene and a cariogenic diet.
Not only will decalcification occur around the
brackets but tooth movement in the presence of
active gingivitis or periodontal disease will
accelerate any bone loss. Attempting to move
teeth in the presence of active dental disease can
have disastrous consequences and must be
avoided.
Therefore, treatment for patients with ques-
tionable dental health should be confined to

extractions and spontaneous alignment of the
teeth only. Figure 2 illustrates a case where there
is an obvious need for orthodontic treatment but
this was precluded by the patient's extremely
poor oral hygiene.
Minor apical root resorption is a common
consequence of orthodontic tooth movement.
However, this resorption can occasionally be
severe. Tooth movement in the presence of apical pathology is known to accelerate resorption
and should be dealt with prior to commencing
treatment.
Lower arch
The lower arch should be examined and planned
in the first instance. Whatever treatment is carried out in the lower arch often determines the
treatment to be carried out in the upper. Examine
the teeth for any tipping, rotations and crowding. Teeth which are tipped mesially are much
more amenable to treatment, both with removable and fixed appliances than teeth which are
distally tipped. They also respond much better to
extractions and spontaneous alignment than
other teeth. The presence or absence of rotations
is important because rotated teeth are most easily
treated with fixed appliances. The more crowded
the teeth are the more likely it is that extractions
will be needed in order to correct the malocclusion. A method of assessing crowding is given in
Figure 3. Firstly, measure the size of the teeth
and add these together (length A). Then measure
from the mid-line to the distal of the canine with
a pair of dividers. Measure from the distal of the
canine to the mesial of the first permanent
563
PRACTICE
Upper arch
This is examined in a similar way to the lower
arch. Additional points to note in the mixed dentition are the presence of a mid-line diastema
and the position of the upper canines.
A mid-line diastema is commonly seen in the
mixed dentition. The aetiological factors to be
considered are:
Fig. 1 Decalcification
attributable to fixed
appliances and a patient with
poor oral hygiene throughout
treatment
Fig. 2 This patient has

a reasonable need for
orthodontic treatment,
but the poor oral hygiene
and gingival condition
precludes this
molar. Add these together to give you the

approximate arch length (length B). Subtract B
from A to give you the degree of crowding. This
must be repeated for both sides of the arch.
The degree of crowing influences the need for
extractions. Although one should not be dogmatic and several other factors influence the
planning of extractions, as a general rule the
greater the crowding the more likely extractions
are necessary. Table 1 gives an outline of the
relation between degree of crowding and need
for extractions.
Table 1 Relationship between crowding and
extractions
Degree of crowding
Physiologic spacing usually disappears as the

occlusion matures, especially when the upper
permanent canines erupt and no treatment apart
from observation is needed. Fraenectomies are
rarely indicated and generally do not need to be
removed unless the fraenum is particularly large
and fleshy.
The upper permanent canine should be palpable in the buccal sulcus by 10 years of age.
If not, and the deciduous canine is firm, parallax
radiography should be undertaken to determine
where the permanent tooth is. If the tooth is
palatally positioned then the deciduous canines
on both sides should be removed. This will help
guide the permanent tooth into a more
favourable path of eruption and prevent any
centre line shift caused by a unilateral deciduous
extraction. It is essential that this palpation be
carried out on all patients in this age group. Very
often impacting canines are missed and the
patient not referred for treatment until 15 or 16
years of age. Not only is this negligent, but the
patient may then need to undergo a lengthy
course of treatment at a socially difficult time.
Teeth in occlusion
The overjet and overbite should be measured
and the incisor classification assessed. The
British Standards Institute (BS EN21942 Part 1
(1992) Glossary of Dental terms) defines the
incisor classification as follows:
Need for extractions
< 5 mm
510 mm
> 10 mm
Normal (physiological) development

Fraenum
Small teeth
Missing teeth
Midline supernumerary
No
Possibly
Yes
1
2
Fig. 3 Assessment of
crowding. The widths of
all the teeth anterior to
the molars are measured
and subtracted from the
sum of two measurements
(mesial of the lower
incisor to the distal of the
lower canine, plus distal
of lower canine to the
mesial of the first molar)
to give the degree of
crowding
564
1+2 = B
1+2+3+4+5 = A
B A = Degree of crowding
PRACTICE
Fig. 5 Method for recording deviations in the

centre line where the lower is to the right by 1mm
and the upper to the left by 2 mm
Class I. The lower incisor edges occlude with

or lie immediately below the cingulum plateau
(middle part of) the upper central incisors.
Class II. The lower incisor edges lie posterior
to the cingulum plateau of the upper central
incisors. There are two divisions:
Division 1 there is an increase in the overjet
and the upper central incisors are usually
proclined.
Division 2 the upper central incisors are
retroclined. The overjet is usually minimal but
may be increased.
Class III. The lower incisor edges lie anterior
to the cingulum plateau of the upper central
incisors. The overjet is reduced or reversed.
The centre line should be measured by placing a ruler down the patient's facial mid-line and
measuring how far away from this the centre
lines deviate (Fig. 4). This can then be marked in
the notes as shown in Figure 5.
The buccal occlusion is assessed next, particularly the molar relationship. This is important because when assessing the treatment, it
has to be decided whether the buccal occlusion
is to be accepted or whether it should be corrected as part of the treatment plan. The canine
and molar relationships should be recorded as
class I, II or III
Finally, the presence of any anterior or posterior cross-bites should be assessed and if
there is a cross-bite, the clinician should check
to see whether there is any mandibular displacement associated with it. This is important
because any displacement will mask the position of the teeth and give a misleading indication of the inter-occlusal relationships. Figure 6
shows a child who has an apparently severe
class III incisor relationship. However, he can
get his teeth into an edge-to-edge relationship
and in this position the occlusion does not
appear to be so severe. The amount of proclination of the upper incisors needed to correct
the incisor relationship was quite mild and
easily accomplished using a removable appliance (Fig. 7 and 8).
Fig. 4 Measurement of centre line

deviation using a ruler placed in
the patient's mid line
Fig. 6 Class III

malocclusion with a
displacement
anteriorly. The patient
can achieve an edge to
edge incisor relation in
the retruded position
of the mandible
Fig. 7 Upper removable appliance used to correct the

anterior cross bite
Fig. 8 The corrected
incisor position for
the patient
565
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PRACTICE
IN BRIEF
Treatment planning is an essential part of orthodontic management

Consider the treatment aims first, then the treatment plan
The teeth and periodontium must be healthy before starting orthodontic treatment
To help ensure a successful treatment outcome the oral hygiene and diet must be good
Choosing the correct appliance is important
VERIFIABLE
CPD PAPER
Orthodontics. Part 4: Treatment planning

The treatment plan is an integral part of orthodontic management. It should be divided into
both treatment aims (what do you want to do?) and plan (how are you going to do it?). The
treatment aims will include, for example overjet reduction. The plan will consider how to
create space in order to accomplish this as well as the appliance system that will be used.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment

Refereed Paper
doi:10.1038/sj.bdj.4810820
683685
Treatment planning is the second most

important part of orthodontic management
following the patient examination. It is helpful to divide treatment planning into two sections, treatment aims and treatment plan.
Although it is possible that orthodontic treatment can influence the skeletal form when
growth-modifying (functional) appliances
are used, it has little effect on soft tissues,
tooth size and arch length. Remember that it
is not necessary to treat every malocclusion
and the benefits to the patient should be
carefully assessed prior to undertaking any
orthodontic treatment.
Relieve crowding
The decision to extract teeth needs to be carefully considered and depends on the degree of
crowding, the difficulty of the case and the
degree of overbite correction.
Correct the buccal occlusion
The key to upper arch alignment is to get the
canines into a Class I relationship (Fig. 1).
TREATMENT AIMS
The following list is not comprehensive and has
to be tailored to the individual case. Some of the
problems that may need to be addressed during
treatment are:
Improve dental health

Relieve crowding
Correct the buccal occlusion
Reduce the overbite
Reduce the overjet
Align the teeth
As emphasised previously, it is essential that

the oral health is of a high standard before treatment starts. Carious teeth should be restored and
the periodontal condition and oral hygiene
should be excellent before treatment starts.
BRITISH DENTAL JOURNAL VOLUME 195 NO. 12 DECEMBER 20 2003
Fig. 1 It is important to achieve a Class I canine

position in order to fully correct the overjet and
the buccal segment relations
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PRACTICE
Fig. 2 The importance of

keeping extraction patterns
symmetrical is demonstrated.
The lower arch crowding has
been dealt with by removal of
two lower premolars. The loss
of the corresponding upper
premolars means the molar
relationship at the end of
treatment should be Class I
Providing the lower incisors are well aligned,

achieving this will generally produce sufficient space to align the upper incisors.
In order to get the canines Class I there are, in
general two choices for the molar relationship at
the end of treatment; either Class I or a full unit
Class II. This will be covered in more detail later
in the section on treatment plan.
Overbite and overjet reduction

The overbite should always be reduced before
overjet reduction is attempted. A deep overbite
will physically prevent the overjet from being
reduced because of contact between the upper
and lower incisors.
Retention
Once the overjet has been reduced and or upper
incisors have been aligned a retainer should be
fitted. These are designed to reduce the risk of

relapse post treatment by allowing remodelling
and consolidation of the alveolar bone around
the teeth and reorganisation and maturation of
the periodontal fibres. There are many different
types of retainers but they are generally removable or fixed. There are no hard and fast rules
regarding the length of time retention should
continue. The authors recommend for removable
appliance treatment that retention should continue for 3 months full time and 3 months at
night-time only. For fixed appliance cases this
should be 3 months full time and a minimum of
9 months at night-time only. At the end of this
minimum years worth of retention, discretionary wear should be advised. This means that
the patient is given the option of discarding the
retainer if they are fed up with wearing it, or
continuing on a part-time regime to give the
teeth the best possible chance of staying
straight. If they decide to stop wearing the
retainer they should be warned there is no guarantee that the teeth will remain straight
throughout life and the only way to improve this
prospect is by indefinite (ie life-long) wearing of
the retainer.
Some cases, especially those that were spaced
or where rotations were present prior to treatment, should be retained indefinitely, usually
with bonded retainers.
TREATMENT PLAN
The treatment plan should be considered as
follows:
Oral health
Lower arch
Upper arch
Buccal occlusion
Choose the appliance
Oral health
Tooth brushing and diet advice must be given
and written in the notes. Daily fluoride rinses are
also recommended. Caries must be treated and
periodontal problems appropriately addressed.
Fig. 3 Where upper premolars

alone are extracted (assuming
no crowding in the lower arch),
reduction of the overjet and
space closure means the molar
relationship must be a full
unit Class II
684
Lower arch
Plan the lower arch first. The size and form of
the lower arch should generally be accepted.
Excessive expansion in the buccal regions or
proclination of the lower incisors is contraindicated in most cases because the soft tissues will generally return the teeth to their
original position.
The need for extractions depends on the
degree of crowding. In some cases, slight proclination of the lower incisors and expansion in
the lower premolar region is acceptable,
although this should be kept to a minimum in
carefully planned cases. Generally this type of
treatment is confined to the correction of mild
crowding (less than 5 mm), cases where incisors
have been retroclined by a digit habit or trapped
in the vault of the palate, or during development
of Class II Division 2 malocclusions especially
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PRACTICE
where there is a deep bite. Any case where the
overbite is excessive must be very carefully
assessed before extraction decisions are made.
As the degree of crowding increases from
510 mm the need for extractions increases and
with more than 10 mm of crowding extractions
are nearly always required. If spontaneous
alignment or removable appliances are to be
used, first premolars are usually the extraction
of choice because they are near to the site of
crowding, allow the canines to upright and produce the best contact point relationship. If other
teeth are to be extracted then generally fixed
appliances will be required. Crowding tends to
worsen with age and is thought to be related to
facial growth which continues at least until the
fifth decade.
Upper arch
Plan the upper arch around the lower. If extractions are undertaken in the lower arch these
should generally be matched by extractions in
the upper. If no extractions are carried out in the
lower arch the space for upper arch alignment
may come from either distal movement of the
upper buccal segments or extraction of upper
premolars. The choice depends on the space
requirements and the buccal occlusion. As the
degree of crowding and overjet increase, then
the space requirements will also increase and it
is more likely that extractions as opposed to distal movement will be indicated.
Determine whether the teeth are favourably
positioned for spontaneous alignment. If appliances are needed can removable or fixed appliances accomplish the tooth movements?
Plan the buccal occlusion
Consider whether this needs to be corrected and
if so how. If headgear is to be used, should it be
used in conjunction with a removable or a fixed
appliance? If the lower arch is crowded, space
may be created by the removal of two lower premolars. This is then matched by upper premolar
extractions and the molar relationship must be
Class I at the end of treatment to allow the arches to fit together (Fig. 2).
However if the lower arch is well aligned,
space to align the upper arch can be created by
either upper premolar extractions or by distal
movement of the upper buccal segments. The
choice depends on how much space is required
and what the molar relationship is at the start
of treatment. Generally the more Class II the
molars are the more likely one will opt for premolar extraction rather than distal movement.
Moving molars more than 34 mm distally is
Fig. 4 Where a relatively small

Class II correction is required
this can be achieved through
distal movement of the molars.
The loss of upper premolars in
this case would produce an
excess of space
possible but becomes increasingly demanding

on patient co-operation. In circumstances
where the space requirements are large, upper
premolar extraction reduces the treatment
time and increases patient compliance. Figure
3 shows the sequence of events when upper
premolar extraction alone is undertaken as an
aid to overjet reduction.
The nearer to Class I the initial buccal occlusion is, the more likely it will be that distal
movement is appropriate. Therefore, space
requirements that involve less than half a unit
Class II correction can be accomplished by distal
movement of the molars in a relatively short
time with more chance of good patient co-operation (Fig. 4). Extracting upper premolars in
these cases produces an excess of space and may
increase the treatment time.
Choose the appliance

Once the need for extractions has been considered the appropriate appliance should be selected. This can involve allowing some spontaneous
alignment to occur, using removable, fixed or
functional appliances with the addition of extraoral traction or anchorage. Appliance choices
are covered in the next section.
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PRACTICE
IN BRIEF
The correct appliance choice is essential for optimum treatment outcome

Removable appliances have an important but limited role in contemporary orthodontics
Fixed appliances are usually the appliance of choice
Functional appliances are helpful in difficult cases but may not have an effect on
facial growth
Extra-oral devices include headgear, face-masks and chin-caps
VERIFIABLE
CPD PAPER
Orthodontics. Part 5: Appliance choices

NOW AVAILABLE
AS A BDJ BOOK
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
1Orthodontic Department, Leeds Dental
There are bewildering array of different orthodontic appliances. However, they fall into four
main categories of removable, fixed, functional and extra-oral devices. The appliance has to
be selected with care and used correctly as inappropriate use can make the malocclusion
worse. Removable appliances are only capable of very simple movements whereas fixed
appliances are sophisticated devices, which can precisely position the teeth. Functional
appliances are useful in difficult cases and are primarily used for Class II Division I
malocciusions. Extra-oral devices are used to re-enforce anchorage and can be an aid in
both opening and closing spaces.
There are four main types of types of appliance

that can be used for orthodontic treatment.
These are removable, fixed, functional and extra
oral devices.
REMOVABLE APPLIANCES
In general these are only capable of simple tooth
movement, such as tipping teeth. Bodily movement is very difficult to achieve with any degree
of consistency and precise tooth detailing and
multiple tooth movements are rarely satisfactory.
These appliances have received bad press over
the past few years because studies have shown
that the treatment outcomes achieved can often
be poor.1,2 In these studies as many as 50% of
cases treated with removable appliances were
either not improved or worse than at the start of
treatment. When faced with evidence such as
this, one might be justified in discarding removable appliances completely. However, provided
they are used in properly selected cases they still
can be very useful devices and the treatment
outcome can be satisfactory.3 In general, removable appliances are only recommended for the
following:
Institute, Clarendon Way, Leeds LS2 9LU;

2Division of Child Dental Health, University
of Bristol Dental School, Lower Maudlin

Street, Bristol BS1 2LY
Refereed Paper
doi:10.1038/sj.bdj.4810872
918
Thumb deterrent
Tipping teeth
Block movements
Overbite reduction
Space maintenance
Retention
BRITISH DENTAL JOURNAL VOLUME 196 NO. 1 JANUARY 10 2004
Thumb deterrent
Digit sucking habits which persist into the
teenage years can sometimes be hard to break
and may result in either a posterior buccal cross
bite or an anterior open bite with proclination of
the upper and retroclination of the lower incisors. In general, if the habit stops before facial
growth is complete then the anterior open bite
usually resolves spontaneously and the overjet
returns to normal.4
Figs. 1ac show a case with an anterior
open bite associated with an avid digit sucking habit. A simple upper removable appliance
was used successfully to stop the habit. The
appliance simply makes the habit feel less of a
comfort and acts as a reminder to the patient
that they should stop sucking the thumb.
Complex appliances with bars or tongue cribs
are rarely needed. In this patient once the
habit had stopped the open bite closed down
on its own without the need for further orthodontic treatment.
Tipping
One of the major uses of removable appliances
is to move one incisor over the bite as shown in
Figs 2ad. A simple upper removable appliance
utilized a T spring constructed from 0.5 mm
wire activated 12 mm which delivered a force
of about 30 g to the tooth. After only a few
weeks the cross bite was corrected without the
need for complex treatment. Note the anterior
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PRACTICE
Fig. 1ac A 9 year-old patient with an anterior

open bite caused by a thumb sucking habit. Note
the wear on the thumb as a result of this. She
was fitted with a simple upper removable
appliance and gently encouraged to stop the
habit. She did so successfully and the open bite
closed down spontaneously in 6 months
Fig. 2a an anterior cross bite involving the upper

left and lower left central incisors
Fig. 2b An upper removable appliance with Adams

cribs for retention made from 0.7 mm wire on the
first permanent molars and the upper left central
incisor. A T spring made from 0.5 mm wire is
used to push the tooth over the bite. The anterior
retention is to prevent the front of the appliance
being displaced as the spring is activated
Fig. 2c The appliance in place. The T spring is

activated 12 mm every 4 weeks
Fig. 2d The completed case. Active treatment took

12 weeks
retaining clasp that prevents the appliance

from displacing downwards when the spring is
activated.
If teeth are to be pushed over the bite with
removable appliances, a stable result is more
likely to be achieved if the tooth is retroclined in
the first instance, the overbite is deep and there
10
is an anterior mandibular displacement associated with a premature contact. Tipping teeth

tends to reduce the overbite because the tip of
the tooth moves along the arc of a circle as
shown in Figure 3a. Excessive tipping may also
make the tooth too horizontal which can be not
only aesthetically unacceptable but may also
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PRACTICE
Fig. 3a The effect of tipping anterior

teeth on the overbite. As the teeth
move around a centre of rotation the
incisal tip moves along the arc of a
circle. By the laws of geometry, as
the tooth is proclined the overbite
reduces once it moves past the
vertical
Fig. 3b Excessive tipping not only

reduces the overbite but also makes
the axial inclination of
the teeth too horizontal. In these
situations stability is reduced, the
appearance is poor and the tooth may
suffer from unwanted
non-axial loading
Fig. 4a Both the upper lateral incisors are in cross

bite
Fig. 4b An upper removable appliance was used to

tip the laterals over the bite
Fig. 4c The cross bites have been corrected. Note

the reduction in the overbite
Fig. 4d 6 months later the upper right lateral has

relapsed into cross bite due to the reduced
overbite
result in excessive non-axial loading of the

tooth as illustrated in Figure 3b.
Overbite reduction when teeth are over proclined is illustrated in Figures 4ad. In this case
both the upper lateral incisors were pushed over
the bite with an upper removable appliance. The
cross bite was corrected but note the reduction
in overbite on the lateral incisors. Six months
after completion of treatment the upper right
lateral had relapsed back into cross bite.
Block movements
If a cross bite involves a number of teeth, for
example a unilateral buccal cross bite, removable appliances can be used to correct this. The
sequence of events is shown in Figures 5af.

Adams cribs are generally placed on the first
premolars and the first permanent molars and a
midline expansion screw is incorporated into
the base plate. This midline screw is opened
0.25 mm (one quarter turn) twice a week until
the cross bite is slightly overcorrected. Posterior buccal capping can also be used to disengage the bite and prevent concomitant expansion of the lower arch. Once the cross bite is
corrected the buccal capping can be removed
and the appliance used as a retainer to allow
the buccal occlusion to settle in. Occasionally
two appliances will be needed if a considerable
amount of expansion is needed.
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PRACTICE
12
Fig. 5a Narrowness of the upper arch can produce a traumatic bite
Fig. 5b To avoid painful cuspal contact the patient may move the
mandible to one side producing a mandibular deviation and a cross
bite
Fig. 5c An upper removable appliance with a mid line expansion

screw can be used to correct the cross bite. The screw is opened onequarter turn twice a week by the patient
Fig. 5d The corrected cross bite. The treatment time varies with the
amount of expansion needed but usually takes about twelve weeks
Fig. 5e Once active treatment is completed the appliance can be

worn as a retainer. The posterior capping can be reduced to allow
interdigitation of the buccal teeth thus helping to prevent any
relapse
Fig. 5f The completed case
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PRACTICE
Overbite reduction
Removable appliances are very effective in correcting a deep overbite, especially in a growing
patient. An upper removable appliance with an
anterior bite plane is used which disengages the
molars by 23 mm whilst at the same time
establishing lower incisor contact with the bite
plane (Fig. 6). Eruption of the posterior teeth
produces a reduction in the overbite. It is essential that the inter-incisor angle is corrected at
the completion of treatment so that an occlusal
stop between the upper and lower incisors is
produced preventing re-eruption of the incisors
and a relapse of the overbite. Bite planes are
usually used in conjunction with fixed appliances to help the overbite reduction (Figures
7ad) or can be used as an aid to restoration
of the anterior teeth. Figures 8ad show a
patient with a deep bite who had marked enamel
erosion. Porcelain crowns were to be placed on
the anterior teeth to restore them, but the deep
bite made this technically difficult. The overbite
2-3mm
Fig. 6 Overbite correction with a removable appliance. The posterior teeth

should be separated by about 23 mm
Fig. 7a A case with a deep bite and retroclined

upper incisors
Fig. 7b An upper removable appliance is used to
help the overbite reduction whilst palatal springs
simultaneously move the first permanent
molars distally
Fig. 7c Once the overbite is fully reduced the

upper fixed appliance can be placed
was therefore reduced with a bite plane to make

room for the crowns.
Space maintenance
Space maintainers are rarely indicated in orthodontic treatment but occasionally can be used,
particularly if the upper canine is buccally crowded. Whilst the extraction of the first premolars
will often create space for the canines, there is
a danger that the space will close before the
canine erupts as the buccal teeth drift mesially.
Figures 9ae illustrate such a case where the fitBRITISH DENTAL JOURNAL VOLUME 196 NO. 1 JANUARY 10 2004
Fig. 7d The completed case with good overbite

reduction
ting of a space maintainer proved useful. The

appliance was fitted just prior to the emergence
of the permanent canines. The four first premolars were then extracted and the appliance left in
position until the canines erupted. This took
about 6 months and saved a considerable
amount of extra treatment for the patient by
allowing spontaneous alignment of the canines.
Retention
Many orthodontists use various types of removable appliances to act as retainers, usually at the
13
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PRACTICE
Fig. 8a, b A patient with severe erosion of the

teeth
Fig. 8c A bite plane was used to reduce the

overbite
Fig. 8d Strip crowns were placed on the incisors

once the overbite was reduced
Fig. 9a, b A case with severe upper arch crowding. The upper
permanent canines were unerupted, buccally positioned and
very short of space
Fig. 9c An upper removable space maintainer. Adam cribs have

been placed on the first permanent molars and a Southend clasp
on the upper central incisors
Fig. 9d,e The first premolars have been extracted and the upper canines
are erupting into a good position
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PRACTICE
completion of fixed appliance treatment.
Removable retainers are usually held in position
with Adams Cribs on the first permanent molars
with a labial bow and possible acrylic coverage
of the anterior teeth (Fig. 10).
FIXED APPLIANCES
These appliances are attached to the crowns of
teeth and allow correction of rotations, bodily
movements of teeth and alignment of ectopic
teeth. They have increased in sophistication
enormously over the past 1015 years and
together with advancements in arch wire technology are capable of producing a very high
level of treatment result. Simultaneous multiple
Fig. 10 One example

of the many
different types of
removable retainers
Fig. 11 Rectangular arch wire in rectangular bracket

slots allows three-dimensional control of
the teeth. The tighter the fit of the wire in the slot
the greater the control of the teeth
tooth movements can be achieved, invariably

creating a better treatment outcome than can be
achieved with removable appliances. Although
there are a variety of fixed appliances available
they all operate in a similar way producing a
fixed point of attachment to control the position
of the teeth. Brackets are attached to the teeth
and wires (arch wires) are placed in the bracket
slots to move the teeth. The closer the fit of rectangular arch wires in a rectangular slot on the
bracket the greater the control of the teeth
(Fig 11). As treatment progresses, thicker rectangular wires are used to fully control the teeth in
three dimensions. Fixed appliances are the
appliances of choice for most orthodontic treatBRITISH DENTAL JOURNAL VOLUME 196 NO. 1 JANUARY 10 2004
ment because the results are far more predictable

and of a higher standard achieved than by other
means. However, they are relatively complex
appliances to use and further training in these
devices is essential. An example of a case treated
with fixed appliances is shown in Figure 12aj.
The anchorage requirements for the bodily
movement of teeth are considerably greater than
for tipping movements (Fig. 13).
FUNCTIONAL APPLIANCES
These are powerful appliances capable of impressive changes in the position of the teeth. They
are generally used for Class II Division I malocclusions although they can be used for the
15
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PRACTICE
Fig. 12c Upper first and lower second

premolars were extracted and the canines
surgically exposed
Fig. 12e Full fixed appliances were then used to reduce the over bite
and overjet, move the apex of the canine into the line of the arch and
correct all the other features of the malocclusion. The initial arch
wire was a very thin flexible wire. If a thick wire is used at this stage
excess force will be applied to the teeth that can produce root
damage and be very painful for the patient
Fig. 12h,i The

completed case.
The canine is fully
aligned and the
overjet reduced
without any
unwanted tipping
of the teeth
16
Fig. 12a, b Pre treatment photographs of a patient with palatally

impacted canine, a buccal cross bite, an increased overjet and
crowding in both arches
Figs 12f,g Once initial alignment of the teeth is produced

progressively thicker, stiffer wires are employed. Because these fit
the bracket slot more closely they control tooth position more
precisely than the thinner aligning wires
Fig. 12d A tri-helix was used to expand the upper

arch and a sectional fixed appliance used to pull
the canine into the line of the arch
Fig. 12j Appropriate extractions

and treatment mechanics have
not been detrimental to the facial
appearance
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PRACTICE
correction of Class II Division II and Class III
malocclusions on occasion. They are either
removable from the mouth or fixed to the teeth,
and work by stimulating the muscles of mastication and soft tissues of the face. This produces a
distalising force on the upper dentition and an
anterior force on the lower. Whilst they are capable of substantial tooth movement, like all
removable appliances they are not capable of
precise tooth positioning and cannot deal effectively with rotations or bodily tooth movement.
There is some controversy as to the precise
mode of action of functional appliances. Some
clinicians feel they have an effect on this facial
skeleton, promoting growth of the mandible
and/or maxilla. Others feel that the effects are
mainly dento-alveolar and that the results
achieved are accomplished by tipping the upper
and lower teeth. Unfortunately many of the studies relating to functional appliance treatment
have been poorly constructed and their conclusions should be treated with caution. A largescale, prospective, randomized clinical trial
currently being undertaken in United Kingdom
strongly suggests that 98% of the occlusal
Fig. 13 Bodily movement of the teeth requires a greater degree of

force than tipping movements
Fig. 14a,b Pre-treatment

photographs of a 12-yearold girl with an increased
overjet and a class II skeletal
pattern associated with a
retrognathic mandible
Fig. 14c A functional

appliance was used to
correct the saggital
relationship
Fig. 14e,f The

facial appearance
following
treatment
Fig. 14d The final result

after detailing of the
occlusion with fixed
appliances
17
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Fig. 15 Extra-oral traction

applied via an Interlandii
headgear
Fig. 16a,b A facemask or reverse headgear
correction is by tipping of the teeth with an

almost negligible effect on the skeletal pattern.5
Nevertheless, dramatic occlusal changes are possible with these appliances and they can aid the
correction of some quite severe malocclusions.
Figures14af show a case treated with a functional appliance that had a marked effect not only on
the occlusion but also on the patient's facial
appearance.
rior cross bite or in cases where the buccal segments are being moved forward to close spaces in
the arches. Examples of extra oral traction
devices are shown in Figures 15, 16a and b. Chin
caps have been used to try and restrain mandibular growth in Class III malocclusions. However,
the evidence from the literature suggests that they
are not terribly effective and their use has
declined in recent years.
EXTRA-ORAL DEVICES
These are headgear devices, chin caps and face
masks, which are used to provide an external
source of anchorage or traction for teeth in one or
both arches. The commonest type is headgear for
the distal movement of the buccal teeth. A metal
face bow is attached to either a removable or a
fixed appliance inside the mouth and elastic traction applied to it. As well as force being applied
distally to either the maxilla or the mandible it
can be applied mesially via a facemask. This is
typically used in Class III cases to correct an ante-
1.
2.
3.
4.
5.
Richmond S, Shaw W C, O'Brien K D et al. The development of

the PAR index (Peer Assessment Rating): reliability and validity.
Eur J Orthod 1992; 14: 125-139.
Richmond S, Shaw W C, Roberts C T, Andrews M. The PAR index
(Peer Assessment rating): methods to determine the outcome
of orthodontic treatment in terms of improvements and
standards. Eur J Orthod 1992; 14: 180-187.
Kerr W J S, Buchanan I B, McColl J H. The use of the PAR index in
assessing the effectiveness of removable orthodontic
appliances. Br J Orthod 1993; 20: 351-357.
Leighton B C. The early signs of malocclusion. Trans Europ
Orthod Soc 1969; 353-368.
O'Brien K, Wright J, Conboy F et al. Effectiveness of treatment
for Class II malocclusion with the Herbst or twin-block
appliances: a randomized, controlled trial. Am J Orthod
Dentofacial Orthop 2003; 124: 128-137.
One Hundred Years Ago

A letter to the BDJ highlighting the concerns of one of its members.
Sir, - There is a movement on foot to establish a Section of Dental Surgery in the
British Medical Association, of which membership is only possible to those members of
the British Dental Association who are on the Medical register.
I beg you most emphatically to protest against any new section, or society of dental
surgeons being formed to which every member of the British Dental Association is not
eligible. I am strongly in favour of every dentist being a surgeon as well (if possible), but
I protest against a revival of the Association of Surgeons practising Dental Surgery in
this insidious form.
Yours truly
S. J. Hutchinson, M. R. C. S., LDS.Eng
BR Dent J, 1903; 24: 828
18
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IN BRIEF
Before any active orthodontic treatment is considered it is essential that the oral hygiene is
of a high standard and that all carious leions have been dealt with
Arch wires, headgears and brackets themselves may cause significant damage either during
an active phase of treatment or during debonding. Much care needs to be taken when
instructing patients about their role in orthodontic treatment
The aim of this section is to outline potential risks in orthodontic treatment and to give
examples. There are also a number of illustrations to help highlight these points
6
VERIFIABLE
CPD PAPER
Orthodontics. Part 6: Risks in orthodontic treatment

H. Travess1, D. Roberts-Harry2 and J. Sandy3
Orthodontics has the potential to cause significant damage to hard and soft tissues. The most important aspect of
orthodontic care is to have an extremely high standard of oral hygiene before and during orthodontic treatment. It is
also essential that any carious lesions are dealt with before any active treatment starts. Root resorption is a common
complication during orthodontic treatment but there is some evidence that once appliances are removed this resorption
stops. Some of the risk pointers for root resorption are summarised. Soft tissue damage includes that caused by
archwires but also the more harrowing potential for headgears to cause damage to eyes. It is essential that adequate
safety measures are included with this type of treatment.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
1Senior Specialist Registrar, 2 Consultant
Orthodontist, Orthodontic Department,

Leeds Dental Institute, Clarendon Way,
Leeds LS2 9LU; 3Professor of Orthodontics,
Division of Child Dental Health, University
of Bristol Dental School, Lower Maudlin
Street, Bristol BS1 2LY
Refereed Paper
doi:10.1038/sj.bdj.4810891
7177
If orthodontic treatment is to be of benefit to a

patient, the advantages it offers should outweigh
any possible damage it may cause.1 It is important to assess the risks of treatment as well as the
potential gain and balance these aspects of treatment before deciding to treat a malocclusion.
The psychological trauma of having orthodontic
treatment, or indeed not having treatment
should not be overlooked and is an important
consideration in treatment planning. Patient
selection plays a vital role in minimising risks of
treatment and the clinician should be vigilant in
assessing every aspect of the patient and their
malocclusion. However, clinically there are a
number of areas of concern for risk management. These are discussed in detail under the
broad categories of intra-oral, extra-oral and
systemic risks.
INTRA-ORAL RISKS
Enamel demineralisation/caries
Enamel demineralisation, usually on smooth surfaces, is unfortunately a common complication
in orthodontics; figures range from 296% of
orthodontic patients (Fig.1).2 This large variation
probably arises as a result of the variety of methods used to assess and score the presence of
decalcification. There is also inconsistency on
whether idiopathic lucencies are included or
excluded in the study design.3 The teeth most
commonly affected are maxillary lateral incisors,
maxillary canines and mandibular premolars.4
However, any tooth in the mouth can be affected,
and often a number of anterior teeth show decal-
Fig. 1 Decalcification on labial surfaces of

numerous teeth
cification. Whilst the demineralised surface

remains intact, there is a possibility of remineralisation and reversal of the lesion. In severe cases,
frank cavitation is seen which requires restorative intervention (Figs. 2 and 3).
Gorelick et al.5 in a study on white spot formation in children treated with fixed appliances,
found that half of their patients had at least one
white spot after treatment, most commonly on
maxillary lateral incisors. The length of treatment did not affect the incidence or number of
white spot formations, although O'Reilly and
Featherstone6 and Oggard et al.7 found that
demineralisation can occur rapidly, within the
first month of fixed appliance treatment. This
has obvious aesthetic implications and highlights the need for caries rate assessment at the
beginning of treatment. Interestingly, Gorelick
et al.5 found no incidence of white spot formation associated with lingual bonded retainers,
which would suggest salivary buffering capacity, and flow rate have a role in protection against
acid attack.
71
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Fig. 2 Cavitation at the gingival margin of

the lower right canine and first premolar
requiring restoration
Fig. 3 Obvious caries in the disto-occlusal

aspect of a lower molar
Good oral hygiene

is essential
for successful
orthodontic
treatment
Daily fluoride
rinses may prevent
and reduce
decalcifications
Care is needed
when debracketing
as there is the
potential for
enamel damage
especially with
ceramic brackets
72
The dominant hand may also influence the

area of decalcification as brushing is more difficult on the side of the dominant hand. Whilst
good oral hygiene is vital, dietary control of
sugar intake is also needed in order to minimise
the risk of decalcification. Fluoride mouthwashes used throughout treatment can prevent white
spot formation8 surprisingly, compliance with
this is low (13%). Other fluoride release mechanisms include fluoride releasing bonding agents,
elastic ligatures containing fluoride, and depot
devices on upper molar bands.9
Preventive measures to minimise damage
include patient selection, vigorous oral hygiene
measures and dietary education. Reinforcement
of oral hygiene and dietary education should be
performed at each visit. Positive reinforcement
even where oral hygiene is satisfactory will
encourage the patient further. Inspection of the
labial surfaces of the teeth at each adjustment
appointment will identify cases that require more
intervention and advice. It is important when
examining the teeth that they are plaque-free
otherwise early demineralisation may be missed.
This can be done by instructing the patient to
clean their teeth in the surgery with or without the
wires in place, or by professional prophylaxis. The
use of auxillaries such as dental health educators
and hygienists is highly desirable. Removal of the
appliance in cases with extreme demineralisation
or poor hygiene is the last resort, but should not
be discounted by the clinician.
Where demineralisation is present post treatment, fluoride application either via toothpaste,
or by adjunct fluoride mouthwash (0.05% sodium fluoride daily rinse or 0.2% sodium fluoride
weekly rinse), can be helpful in remineralising
the lesion and reducing the unsightliness of the
decalcification.10 Acid/pumice micro abrasion
has also been advocated to improve the aesthetics of stabilised lesions.11,12 This procedure
should be delayed at least 3 months following
debond to allow for spontaneous improvement
of the lesions and remineralisation with fluoride
applications.13 Persistent lucencies should be
abraded with 18% hydrochloric acid in fine
pumice under rubber dam in bursts of 30 seconds for a maximum of 10 times. After the last
application the tooth is washed well and a fluoride varnish applied.11
Enamel trauma
When placing appliances careless use of a band
seater can result in enamel fracture. Care is
required when large restorations are present
since these can result in fracture of unsupported
cusps.14 Debonding can also result in enamel
fracture, both with metal and ceramic brackets
(Fig. 4).15,16 Care must always be taken to
remove brackets and residual bonding agents
appropriately to minimise the risk of enamel
fracture. The use of debonding burs has the
potential to remove enamel, especially in air turbine fast handpieces. Care and attention is needed when adhesives are removed.
Enamel wear
Wear of enamel against both metal and ceramic
brackets (abrasion) may occur. It is common on
upper canine tips during retraction as the cusp
tip hits the lower canine brackets (Fig. 5). It may
also be seen on the incisal edges of upper anterior teeth where ceramic brackets are placed on
lower incisors.17 Ceramic brackets are very
abrasive and therefore contraindicated for the
lower anterior teeth where there is any possibility of the brackets occluding with the upper
teeth, bearing in mind that the overbite may
Fig. 4 Enamel fracture at debond
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Short roots are more at risk of resorption than
average length roots.
Teeth previously traumatised, have an
increased risk of further resorption.
Non vital teeth and root treated teeth have an
increased risk of resorption.
Heavy forces are associated with resorption,
as well as the use of rectangular wires, Class II
traction, the distance a tooth is moved and the
type of tooth movement undertaken.
Combined orthodontic and orthognathic procedures.
Fig. 5 Upper canine tip showing abrasion from the
lower canine metal bracket
increase in the early stages of treatment. Any

enamel erosion must be recorded prior to treatment commencing and appropriate dietary
advice given to minimise further tooth substance loss. Carbonated drinks and pure juices
are the commonest causes of erosion and should
be avoided in patients with fixed appliances.
Pulpal reactions
Some degree of pulpitis is expected with
orthodontic tooth movement which is usually
reversible or transient. Rarely it leads to loss
of vitality, but there may be an increase in
pulpitis in previously traumatised teeth with
fixed appliances. Light forces are advocated
with traumatised teeth as well as baseline
monitoring of vitality which should be repeated three monthly.18 Transient pulpitis may
also be seen with electrothermal debonding of
ceramic brackets19 and composite removal at
debond.20
Root resorption
Some degree of external root resorption is
inevitably associated with fixed appliance
treatment, although the extent is unpredictable.21 Resorption may occur on the apical
and lateral surface of the roots, but radiographs
only show apical resorption to a certain degree.
Many cases will not show any clinically significant resorption but, microscopic changes are
likely to have occurred on surfaces which are
not visualised with routine radiographs.
Resorption however rarely compromises the
longevity of the teeth.22 Vertical loss of bone
through periodontal disease creates a far
greater loss of attachment and support than its
equivalent loss around the apex of a tooth.
The mechanism of tooth resorption is unclear.
Theories include excessive force and hyalinisation of the periodontal ligament resulting in
excessive cementoclast and osteoclast activity.
What is clear are the risk factors which are associated with cases with severe resorption. These
can be summarised as:
Blunt and pipette shaped roots show a greater
amount of resorption than other root forms.
Treatment of ectopic canines may induce

resorption of the adjacent teeth because of the
length of treatment time and the distance the
canine is moved. Tooth intrusion is also associated with increased risk as well as movement of
root apices against cortical bone. Above the age
of 11 years the risk of resorption with treatment
seems to increase. Adults have shorter roots at
the outset and the potential for resorption is
increased.
Opinion is divided on whether treatment
length is associated with increased resorption. Some find no correlation with treatment
time, whereas others find that there is
increased resorption with increased treatment
time. In a few patients systemic causes may
contribute, for example hyperthyroidism, but
for the most part no underlying cause is isolated other than individual susceptibility.
Familial risk is also known.
A wide range in the degree of resorption is
seen, highlighting the role of individual susceptibility over and above the risk factors
identified. Research is still required in this area
to identify the mechanisms of resportion, trigger factors and reparative mechanisms if treatment modalities are to be modified in the
future to minimise root damage. Currently, no
case is immune from the risk of root resorption, to some degree, and patients should be
warned at the outset of treatment that such a
risk exists. Recognition of specific risk factors,
accurate radiographs and interpretation of
radiographs at the outset of treatment are
important if root resorption is to be minimised.
Once resorption is recognised clinically during
treatment, light forces must be used, root
length monitored six monthly with radiographs and treatment aims reconsidered to
maximise the longevity of the dentition. The
use of thyroxine to minimise root resorption
has been advocated by some authors, but this
is not routinely used.23, 24
Root resorption is
inevitable with
fixed appliance
treatment
On average 1-2 mm
of apical root is lost
during a course
of orthodontic
treatment
Previously
traumatised teeth
have an increased
risk of root
resorption
Periodontal tissues
Fixed appliances make oral hygiene difficult
even for the most motivated patients, and
almost all patients experience some gingival
inflammation (Fig. 6). Resolution of inflammation usually occurs a few weeks after debond,
bands cause more gingival inflammation than
bonds, which is not surprising since the margins of bands are often seated subgingivally.
73
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Fig. 6 Severe gingival inflammation during

fixed appliance treatment. Note the
inflammation covers the headgear tube
and hook on the upper molar band
Fig. 7 Disclosing solution highlighting the areas

of poor oral hygiene in a patient
Fig. 8 Chronic lack of oral hygiene showing accumulation of plaque gingivally and
around the brackets
Fig. 9 Trauma to the cheek from an

unusally long distal length of archwire
resulting in an ulcer
74
For the most part, the literature suggests

that orthodontic treatment does not affect the
periodontal status of patients over the long
term. Patients with pre-existing periodontal
disease require special attention, but bone loss
during treatment does not seem to be related
to previous bone loss. The need for excellent
oral hygiene during treatment must be
emphasised in patients with existing periodontal disease. The use of bonds rather than
bands on molars and premolars may be more
appropriate to eliminate unwanted stagnation
areas. Plaque retention is increased with fixed
appliances and plaque composition may also
be altered. There is an increase in anaerobic
organisms and a reduction in facultative
anaerobes around bands, which are therefore
periopathogenic.25
Oral hygiene instruction is essential in all
cases of orthodontic treatment, and the use of
adjuncts such as electric toothbrushes, interproximal brushes, chlorhexidine mouthwashes, fluoride mouthwashes and regular professional cleaning must be emphasised. However,
patient motivation and dexterity are paramount in the success of hygiene, and there will
always be cases where oral hygiene is unsatisfactory from the outset. This should be carefully considered when advising a patient to have
treatment. Experience shows those patients
who are unable to maintain a healthy oral
environment in the absence of fixed orthodontics will fail spectacularly with braces in place.
Benefit must therefore significantly outweigh
the risk of carrying out treatment in such
patients (Figs. 7 and 8).
Allergy
Allergy to orthodontic components intraorally is exceedingly rare, however, there have
been studies on the nickel release and corrosion of metals with fixed appliances. Gjerdet
et al.26 found a significant release of nickel
and iron into the saliva of patients just after
placement of fixed appliances. However, no
significant difference was found in nickel or
iron concentrations between controls and
subjects where the appliances had been in
place for a number of weeks. The clinical significance of nickel release is as yet unclear,
but should be considered in nickel sensitive
patients. There are a few cases with severe
latex allergies who may be affected by elastomerics or operators gloves.
Trauma
Laceration to the gingivae, and mucosa seen
as areas of ulceration or hyperplasia, often
occur during treatment or between treatment
sessions from the archwire (Fig. 9) and
bonds, especially where long unsupported
stretches of wire rest against the lips. The
use of dental wax over the bracket may help
to reduce trauma and discomfort, (Fig. 10) as
may rubber bumper sleeving on the unsupported archwire (Fig. 11).
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bow must incorporate a safety feature. Failure to
observe safety guidelines on the use of headgear
is medico-legally indefensible.
Fig. 10 Dental wax placed over a bracket can

ease the pain of ulceration in the lip and mucosa
EXTRA-ORAL RISKS
Allergy
Allergy to nickel is more common in extra-oral
settings, most usually the headgear face bow or
head strap. Over 1% of patients have some form
of contact dermatitis to zips and buttons/studs
on clothing. Of these patients, 3% claim to have
experienced a similar rash with orthodontic
appliances (Fig. 12). The use of sticking plaster
over the area in contact with the skin is sufficient to relieve symptoms. Allergy to latex27 and
bonding materials has been reported although
these are rare.
Burns
Burns, either thermal or chemical are possible
both intra- and extra-orally with inadvertent
use of chemicals or instruments. Acid etch, electrothermal debonding instruments and sterilised
instruments which have not cooled down all
have the potential to burn and care should be
taken in their use.
Tempromandibular dysfunction (TMD)
Much attention in the literature has been
focused on the relationship between TMD and
orthodontic treatment. Whilst TMD is common in the orthodontic aged population
whether orthodontic treatment is carried out
or not, there is no evidence to support the
theory that orthodontic treatment causes TMD
or cures it.29 Pre-existence of TMD should be
recorded, and the patient advised that treatment will not predictably improve their condition. Some patients may suffer with increased
symptoms during treatment which must also
be discussed at the beginning of treatment.
Where patients experience symptoms during
treatment, treatment should be directed at
eliminating occlusal disharmony and joint
noises whilst reassuring the patient. Standard
Trauma
Following a well publicised case of eye trauma
in a patient wearing headgear28 a number of
safety headgear products have been designed
and explicit guidelines are now available. These
measures include safety bows (Figs 13 and 14),
rigid neck straps (Fig. 15) and snap release products (Fig. 16) to prevent the bow from disengaging from the molar tubes or acting as a projectile. A survey among British orthodontists found
a 4% incidence of facial injury with headgear. Of
these injuries, 40% were extra-oral and 50% of
these were in the mid face. Two patients were
blind as a result of headgear trauma. Eye injury
is uncommon, but a serious risk and all available
methods of reducing the risk of penetrating eye
injury must be used. Every headgear and Kloehn
Fig. 13 Safety Kloehn bow showing recurved

loops for smooth distal ends to prevent injury
if the bow becomes disengaged
Fig. 11 Ulcer in a patients

lower lip from a long
stretch of unsupported
wire. Bumper sleeve has
been placed along the wire
to prevent further trauma
Fig. 12 Nickel allergy (contact

dermatitis) in a headgear wearer
Fig. 14 Safety Kloehn bow with Nitom locking

mechanism to prevent disengagement from
the molar tube
75
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Fig. 15 Interlandi headgear with a rigid

Masel safety strap to hold the Kloehn
bow and prevent disengagement for
the buccal tubes
treatment regimes may also be indicated eg

soft diet, jaw exercises. We have not reviewed
this area in detail in this section as it is dealt
with under facts and fantasy in the next, but
an excellent overview of the relation between
orthodontics and occlusal relation has recently
been published.30
Profile damage
Extraction of premolars has been condemned
by some with very little evidence, as altering
the facial profile of the patient.31 A large number of studies have shown that there is no significant difference in profiles treated by extraction or non extraction means. Boley et al.32
found that neither orthodontists nor general
dentists could distinguish between extraction
and non extraction treatment by looking at
profile alone. A recent review examined the
effects of orthodontics on facial profie and
concluded that it does not, although it highlights areas where planning is crucial.33 It
should be remembered that soft tissue changes
occur naturally with age, regardless of orthodontic intervention. Proper diagnosis should
take into account skeletal form, tooth position
and soft tissue form to negate the possibility of
any detrimental effect on profile by treatment
mechanics.34
SYSTEMIC RISKS
Cross infection
Spread of infection between patients, between
operator and patient and by a third party should
be prevented by cross infection procedures
throughout the surgery. Use of gloves, masks,
sterilised instruments and 'clean' working areas
are paramount. A medical history must be taken
for every patient to determine risk factors,
76
Fig. 16 Quick release headgear

attachment. The breakaway design allows
the bow to come out of the headgear
tube, but is no longer under tension and
therefore unable to act as a projectile
although cross infection control should be of a

standard to prevent cross contamination
regardless of medical status.
Infective endocarditis
Patients at risk of endocarditis should be treated
in consultation with their cardiologist and within
the appropriate guidelines.35,36 The patient must
exhibit immaculate oral hygiene, antibiotic cover
will be required for invasive procedures such as
extractions, separation, band placement and
band removal. It is recommended that bonded
attachments are used on all teeth to negate the
need for antibiotic cover for both separator and
band placement, as well as removal. This also
reduces the risk of unwanted plaque stagnation
areas. Chlorhexidine mouthwash has been advocated prior to any treatment and in some cases
daily to minimise bacterial loading.36
CONCLUSIONS
Clearly there are a number of sources of potential iatrogenic damage to the patient during
orthodontic treatment. However, severe damage is rare. Severe malocclusions have more to
benefit from treatment than less severe malocclusions, and motivation between such groups
may vary. Individuals should be assessed for
risk factors for all aspects of care. Lack of
treatment can result in damage, physical or
psychosocial. Discontinuation of treatment
without full correction of the malocclusion,
although a last resort, can leave the patient
worse off than before treatment. Good clinical
practice, careful patient selection and information on a patients responsibility are essential
to minimise tissue damage.
The authors are grateful to Francis Scriven , Thomas
Hartridge and Ingrid Hosein for some of the figures and
Jane Western who cheerfully typed this manuscript.
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18.
Shaw W C, O'Brien K D, Richmond S, Brook P. Quality control in

orthodontics: risk/benefit considerations. Br Dent J 1991; 170:
33-37.
Chang H S, Walsh L J, Freer T J. Enamel demineralisation
during orthodontic treatment. Aetiology and prevention. Aus
Dent J 1997; 42: 322-327.
Mitchell L. Decalcification during orthodontic treatment with
fixed appliances An overview. Br J Orthod 1992 ; 19: 199205.
Geiger A M, Gorelick L, Gwinnett A J, Griswold P G. The effect
of a fluoride program on white spot formation during
orthodontic treatment. Am J Orthod Dento Orthop 1988; 93:
29-37.
Gorelick L, Geiger A M, Gwinnett A J. Incidence of white spot
formation after bonding and banding. Am J Orthod 1982;
81: 93-98.
O'Reilly M, Featherstone J. Demineralisation and
remineralisation around orthodontic appliances an in vivo
study. Am J Orthod Dento Orthop 1987; 92: 33-40.
ggard B, Rlla G, Arends J. Orthodontic appliances and
enamel demineralisation. Part 1. Lesion development. Am J
Orthod Dento Orthop 1988; 94: 68-73.
Geiger A M, Gorelick L, Gwinnett A J. Griswold P G. Effect of a
fluoride program on white spot formation during
orthodontic treatment. Am J Orthod Dento Orthop 1988; 93:
29-37.
Marini I, Pelliccioni G A, Vecchiet F, Alessandri Bonetti G,
Checchi L. A retentive system for intra-oral fluoride release
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695-701.
Featherstone J D B, Rodgers B E, Smith M W. Physiochemical
requirements for rapid remineralisation of early carious
lesions. Caries Res 1981; 15: 221-235.
Welbury R R, Carter N E. The hydrochloric acid-pumice
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Artun J, Thylstrup A. Clinical and scanning electron
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McGuinness N. Prevention in orthodontics a review. Dent
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Meister R E. Comparison of enamel detachments after
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mesh bracket: a scanning electron microscope study. Am J
Orthod 1985; 88: 266 (abstract).
Jones M. Enamel loss on bond removal. Br J Orthod 1980;
7: 39.
Swartz M L. Ceramic brackets. J Clin Orthod 1988; 22: 82-88.
Atack N E. The orthodontic implications of traumatised upper
anterior teeth. Dent Update 1999; 26: 432-437.
19. Takla P M, Shivapuja P K. Pulpal response in electrothermal

debonding. Am J Orthod Dento Orthop 1995; 108: 623-629.
20. Zachrisson B U. Cause and prevention of injuries to teeth and
supporting structures during orthodontic treatment. Am J
Orthod 1976; 69: 285-300.
21. Brezniak N, Wasserstein A. Root resorption after orthodontic
treatment Part I Literature review. Am J Orthod 1993; 103:
62-66.
22. Hendrix I, Carels C, Kuijpers-Jagtman A M, Van 'T Hof M.
A radiographic study of posterior apical root resorption in
orthodontic patients. Am J Orthod Dento Orthop 1994; 105:
345-349.
23. Shirazi M, De Hpour A R, Jafari F. The effect of thyroid
hormone on orthodontic tooth movement in rats. J Clin Paed
Dent 1999; 23: 259-264.
24. Loberg E L, Engstrom C. Thyroid administration to reduce
root resorption. Angle Orthod 1994; 64: 395-399.
25. Diamanti-Kipioti A, Gusberti F A, Lang N P. Clinical
microbiological effects of fixed orthodontic appliances.
J Clin Perio 1987; 14: 326-333.
26. Gjerdet N, Erichsen E S, Remlo H E, Evjen G. Nickel and iron in
saliva of patients with fixed orthodontic appliances. Acta
Odont Scand 1991; 49: 73-78.
27. Natrass C, Ireland A J, Lovell C R. Latex allergy in an
orthodontic patient and implications for clinical
management. Br J Oral Maxillofac Surg 1999; 37: 11-13.
28. Booth-Mason S, Birnie D. Penetrating eye injury from
orthodontic headgear: a case report. Eur J Orthod 1988; 10:
111-114.
29. Luther F. Orthodontics and the temperomandibular joint:
where are we now? Part 1 Orthodontic treatment and
temperomandibular disorders. Angle Orthod 1998; 68:
295-304.
30. Davies S J, Gray R M J, Sandler P J, O'Brien K D. Orthodontics
and occlusion. Br Dent J 2001; 191: 539-549.
31. Rushing S E, Silberman S L, Meydrech E F, Tuncay O C. How
dentists perceive the effect of orthodontic extraction on
facial appearance. J Am Dent Assoc 1995; 126: 769-772.
32. Boley J C, Pontier J P, Smith S, Fulbright M. Facial changes in
extraction and non extraction patients. Angle Orthod 1998;
68: 539-546.
33. DiBiase A T, Sandler P J. Does Orthodontics damage faces?
Dent Update 2001; 28: 98-104.
34. Ackerman J L, Proffit W R. Soft tissue limitations in
orthodontics: treatment planning guidelines. Angle Orthod
1997; 67: 327-336
35 Khurana M, Martin M V. Orthodontics and infective
endocarditis. Br J Orthod 1999; 26: 295-298.
36. Hobson R S, Clark J D. Management of the orthodontic
patient at risk from infective endocarditis. Br Dent J 1995;
178: 289-295.
Guest leaders
Guest leaders in the BDJ are there to provide an opportunity for anyone involved in
dentistry (including patients) to write an appropriate comment for publication.
These are published to accompany the usual Leader from the Editor
Submissions must be between 200 and 500 words, typed and double-spaced.
Name, address and telephone number should be supplied, as well as your position
in the dental world.
For further help and guidance, please contact:
The Editor, British Dental Journal, 64 Wimpole Street, London W1G 8YS or
E-mail: k.maynard@bda.org
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IN BRIEF
There is no good evidence that orthodontics cures or causes temporomandibular joint

dysfunction
Extracting teeth does not inevitably result in an altered profile
There is a need for better quality research in many of the controversial areas in orthodontics
7
VERIFIABLE
CPD PAPER
Orthodontics. Part 7: Fact and fantasy in orthodontics

P. Williams1, D. Roberts-Harry2 and J. Sandy3
NOW AVAILABLE
AS A BDJ BOOK
Clinical research has previously lacked good methodology and much opinion was based on
anecdote which is widely regarded as the weakest form of clinical evidence. There are few
randomised control trials in orthodontics which support or refute areas of dogma. The
number of randomised control trials is increasing significantly. There is currently however
no good evidence that orthodontics causes or cures temporomandibular joint dysfunction,
that appropriate extractions in orthodontics ruin patients' profiles, or that the orthodontist
is able to significantly influence facial growth with appliances.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
Orthodontics, like other fields of medicine and

dentistry has its fair share of controversies.
Some of these controversies have haunted the
profession since its inception and some individuals may be reluctant to change their treatment philosophies in the light of new clinical
evidence.
Orthodontics has evolved from many years of
clinical experience, in which the opinions of
respected individuals during the birth of the speciality have determined how orthodontics
should be practised. A problem with this form of
teaching is that it is based on anecdotal experience rather than sound scientific evidence. New
research often highlights inadequacies in these
fundamental teachings, eventually leading to a
change in clinical practice. A trend is emerging
towards evidence-based rather than opinionbased decisions as more and more structured
research is published.
1Specialist Registrar in Orthodontics,

3Professor of Orthodontics, Division of
Child Dental Health, University of Bristol

Dental School, Lower Maudlin Street,
Bristol BS1 2LY; 2*Consultant Orthodontist,
Orthodontic Department, Leeds Dental
Institute, Clarendon Way, Leeds LS2 9LU
Refereed Paper
doi:10.1038/sj.bdj.4810935
143148
EVIDENCE-BASED DECISIONS
Evidence-based dentistry can be defined as: the
conscientious, explicit, and judicious use of current best evidence in making decisions about the
care of individual patients.1 The gold standard
is strong evidence from at least one published
systematic review of multiple well-designed randomised controlled trials. Meta-analysis is a
form of systematic review looking at all the relevant literature whether good, bad or indifferent
and producing a single estimate of the clinical
effectiveness. The advantage of meta-analysis is
that it summarises the available evidence and
because of its systematic nature it can be
appraised rapidly and applied to patient care.2
BRITISH DENTAL JOURNAL VOLUME 196 NO. 3 FEBRUARY 14 2004
There are various levels of evidence beneath

the gold standard, of which the weakest is anecdotal evidence. In the field of orthodontics there
are few well-designed randomised controlled trials which lend themselves to a systematic
review. Currently there are two such reviews,
namely the change of intercanine width following orthodontic treatment and the treatment of
posterior crossbites.3,4
Recently, media attention has focused on
views made by a small number of orthodontists
and general dental practitioners on the adverse
effects of conventional orthodontic treatment.
Much of this has centred on the role of extracting teeth as part of orthodontic therapy to align
teeth, retract protrusive incisors and to camouflage dentally any skeletal disharmonies
between the mandible and the maxillae.
Summary of evidence-based dentistry

Anecdotal evidence is the weakest
form of evidence
Gold standard is a randomised
controlled trial
Orthodontics has little gold standard
evidence
ORTHODONTICS AND TEMPOROMANDIBULAR

DYSFUNCTION
Relatively recently, orthodontists have been
concerned about the possibility of a link between
the orthodontic treatment they provide and temporomandibular dysfunction (TMD) which is a
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Temporomandibular
joint problems are
not caused or cured
by orthodontic
treatment
Litigation forced
orthodontists into
generating objective
scientific research
into the effects of
orthodontic
treatment
144
common finding in the population. Longitudinal

studies show that the prevalence of signs and
symptoms of TMD increases with age and that
the prevalence of signs is greater than the prevalence of symptoms. It has a variable incidence in
an adolescent population between 535%.5
Most of the attempts at relating TMD to
orthodontic treatment have been based on anecdotal evidence or retrospective studies,
approaches that cannot demonstrate a cause and
effect relationship between treatment and disease. An opinion held by a few was that occlusal
interferences induced by orthodontic treatment
would lead to TMD. This extended to the suggestion that orthodontic treatment is needed for
those whose occlusion is not functionally optimal to prevent the development of TMD. A functional occlusion was defined as one in which
intercuspal position should coincide with
retruded contact position, there should not be
any balancing side interferences and there
should be anterior and canine guidance. Guidelines such as these are often referred to as treating to a functionally optimal occlusion and
were advocated by a group of functional orthodontists. One viewpoint from a group of functional orthodontists is that when premolar teeth
are extracted for orthodontic treatment this
leads to TMD because of over retracting the
upper incisors during space closure, forcing the
condyle into a posterior position. It is this posterior position of the condyle within the fossa,
which is presumed to cause an anteriorly displaced disc and therefore TMD.6 It was also
believed that occlusal interferences would lead
to TMD, as well as tooth wear, periodontal disease and instability of tooth position after orthodontic treatment if the position of the condyle
was not rear most, mid most and upper most.
Roth demonstrated that the symptoms of TMD
could be resolved once they were equilibrated
with occlusal positioning splints.7 However,
these conclusions were reached after Roth had
evaluated only nine patients post treatment and
two of these acted as controls.
The debate concerning a relationship
between orthodontic treatment and TMD came
to a head in 1987 following a lawsuit, Brimm vs
Malloy, in which it was claimed that orthodontic
treatment had caused TMD in a patient. During
the trial, the lack of good scientific evidence
investigating the effects of orthodontic treatment and TMD was highlighted and prompted
the formation of the American Association of
Orthodontics Temporo Mandibular Joint
Research Programme. This is perhaps the first
time that orthodontists realised the lack of
objective, scientific research into the effects of
orthodontic treatment. Only recently has
stronger evidence been forthcoming in assessing
the role of orthodontic treatment with respect to
TMD.
A number of studies have examined the position of the condyle and its relationship with
TMD. They found that individuals with normal
joints (ie none have reported any signs or symp-
toms of TMD) had condyles that could be

observed, randomly distributed, in anterior, centric and posterior positions in the glenoid fossa.8
A posterior position of the condyle within the
glenoid fossa cannot therefore be taken as proof
of TMD.
When orthodontic treatment involves the
extraction of upper first premolar teeth and the
retraction of the upper incisors some have suggested that this predisposes the patient to TMD
by posteriorly positioning the condyle. Some
light has been shed on this position in a study of
42 patients with a Class II Division 1 malocclusion treated by the extraction of both upper first
premolars and fixed appliances. Seventy per cent
showed a forward movement of mandibular
basal bone and the changes in condylar position
did not correlate with incisor retraction (ie orthodontic treatment caused a transitory forward
position of the condyle in the intercuspal position with a return to the pretreatment position
after treatment). It was therefore concluded that
orthodontic treatment involving the loss of premolar teeth did not cause TMD and this has been
supported by the finding of other workers.9,10
The suggestion that orthodontic treatment
causes a posteriorly positioned condyle, which
in turn leads to TMD, appears to be ill founded.
The clinical studies published so far conclude
that orthodontic treatment has no role in worsening or causing TMD when treated patients are
compared with untreated patients with or without a malocclusion.11
The final question that should be addressed is
the need to treat our orthodontic cases to a
functionally optimal occlusion. There is little
clinical evidence to suggest that such an occlusion has any benefits in terms of reducing the
following:
Tooth wear
TMD
Periodontal disease
Instability of tooth position
Indeed intercuspal position rarely coincides
with retruded contact position in a good occlusion and it has yet to be shown that canine guidance has an effect of preventing or curing TMD.
A natural dentition with canine guidance will
tend to become group functioning with time as
the canines wear. Furthermore canine guidance
does not seem to offer any protection against
TMD.12
Although canine guidance is often advocated
as the functioning mode of choice, it is often an
unobtainable aim for a substantial proportion of
orthodontic patients. A study investigating the
frequency of group function and canine guidance patterns of occlusion as related to the
Frankfort-mandibular plane angle found the
following. It showed a positive relationship
between canine guidance and low Frankfortmandibular plane angles and of group function
to high Frankfort-mandibular plane angles.13
This would suggest that facial morphology may
indicate which functional goal to aim for.
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There are no clear occlusal objectives for
orthodontic treatment although there are many
occlusal goals which have been suggested.
Occlusal goals are those directed at the relationship of the teeth both in static intercuspal position and during function. Andrews introduced
his six keys to a normal occlusion as a means of
obtaining a static intercuspal position that is
seen as ideal.14 A summary of these six keys is
given below:
Class I molar relationship
Correct crown angulation
Correct crown inclination
No rotated teeth
No interdental spaces
Flat occlusal plane
In practice, orthodontically treated occlusions seldom achieve all occlusal keys because
of differences in skeletal pattern and tooth size
discrepancies.15 It has however been shown that
well intercuspated teeth may be more stable and
less likely to relapse.16
There is a general agreement that intercuspal
position should coincide with retruded contact
position although there is a disagreement as to
how closely they should coincide. The majority
of the population have been shown to exhibit a
discrepancy between the two positions with no
ill effects. It seems sensible therefore to accept
small discrepancies of approximately 1 mm or
so of each other.
Summary of orthodontics and TMD

Extracting teeth does not cause
a posteriorly positioned condyle
Orthodontics does not cause TMD
THE EXTRACTION VERSUS NON-EXTRACTION

DEBATE
The extraction of teeth as part of orthodontic
treatment continually causes controversy. Teeth
are extracted for several reasons in orthodontics.
The most common reason for extraction is the
relief of crowding and the need to create space to
gain good alignment of the teeth. The reduction
of overbite and the correction of an increased
overjet to obtain a Class I incisor relationship are
also important issues to consider where extractions will be required.
Edward Angle was very influential during the
1890s in developing orthodontics as a speciality,
with himself as the father of modern orthodontics. He is credited with much of the development in the concept of occlusion in the natural
dentition and a classification of malocclusion.
Angle believed in non-extraction orthodontic
treatment and that every person had the potential for an ideal relationship of all 32 teeth. He
was also concerned with the ideal facial aesthetics which he felt could be achieved when the
dental arches had been expanded so that all the
teeth were in ideal occlusion. Angle did not
come to this expansion philosophy through clinBRITISH DENTAL JOURNAL VOLUME 196 NO. 3 FEBRUARY 14 2004
ical research but was convinced by the ideas of

influential people of his time, namely Rousseau
and Wolff. It was felt by Rousseau, a philosopher, that many of the ills of modern man were
due to the environment we now live in and
emphasised the perfectibility of man. Therefore
from an orthodontic perspective, a perfect
occlusion could never be achieved by the extraction of teeth. In the early 1900s Wolff, a physiologist, demonstrated that remodelling of bone
could occur in response to functional loading.
Angle therefore reasoned that if teeth were
placed in a proper occlusion, forces transmitted
to the teeth would cause bone to grow around
them. He went as far as describing his edgewise
appliance as the bone growing appliance. Any
relapse seen in any of his treated cases was
attributed to an inadequate occlusion.
It was not until the 1930s and the 1940s that
this non-extraction rule advocated by Angle
was challenged by Tweed and Begg. They both
felt that a malocclusion was an inherited condition and dismissed the notion about the perfectibility of man. Tweed argued about the poor
long term stability of expanded dental arches
and decided to retreat many of Angles cases by
extracting four first premolars. He publicly
demonstrated 100 consecutively treated patients
claiming a more stable occlusion after extraction based treatment. An appliance system was
created by Begg, which was designed to be used
on extraction based treatments, which popularised this treatment approach.
The extraction debate has reopened recently,
especially in North America, because of concerns of litigation if extraction based treatment
philosophies are used. In recent years there has
been a trend towards non-extraction treatment
as studies have shown that even cases treated
with the extraction of first premolars are not
guaranteed a stable result.17
Orthodontic
treatment on
an extraction or
non-extraction basis
will still show some
relapse in most cases
Summary of the extraction versus

non-extraction debate
Changing trends over the years in
extraction/ non-extraction based
treatment
Arch expansion shows worst levels of
relapse
Extracting teeth does not guarantee
future stability
Each case should be properly treatment
planned to give greatest future stability
DOES EXTRACTING TEETH DAMAGE FACES?

Some practitioners in recent years have shown
anecdotal evidence that extracting teeth for
orthodontic purposes ruins a patients profile
and compromises their facial aesthetics. It has
been claimed that the orthodontic extraction of
teeth may cause less attractive smiles with dark
buccal spaces lateral to the buccal segments,
known as the dark buccal corridor, and also by
the retraction of the upper incisors when closing
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Lay populations and

patients cannot
perceive significant
profile changes
after appropriate
orthodontic
treatment which may
or may not involve
orthodontic
extractions
146
the remaining extraction spaces giving a dished

in aged appearance.
These practitioners advocate a non-extraction approach to treatment on the basis that it
will produce a more youthful, protrusive facial
profile a view held by Angle some one hundred years ago. The opinion that non-extraction
treatment is better than extraction treatment
when assessing facial attractiveness is clearly
misinformed given the studies that have now
been carried out.
There is a relationship between retraction of
the upper incisors and the posterior movement
of the upper lip but for any given individual this
is unpredictable. Indeed, when the upper incisors
are retracted by 5 mm it has been shown there is
on average 1.4 mm posterior movement of the
upper lip.9 Those patients treated on an extraction basis have been found to have slightly more
prominent lips compared with those treated on a
non-extraction basis at the end of treatment.18,19
It is of note to mention that in the extraction
group they tended to have more prominent lips
before commencing treatment because of an
increased overjet, an important consideration
when treatment planning these patients. There
are many patients who have been treated on a
non-extraction basis with a dished in appearance and many other patients with fuller profiles
who have had four teeth extracted as part of
their orthodontic treatment. An important consideration before deciding on whether treatment
is going to proceed on an extraction or nonextraction basis is the profile of the patient
before treatment. It is important at this initial
stage of assessment and planning to identify
which patients are vulnerable to worsening an
already flat or dished in profile as they may
not be amenable to orthodontic treatment alone
and may require a combined surgical and
orthodontic approach.
A question frequently raised is that of the differences in facial appearance if the same mildly
crowded case was treated on an extraction or
non-extraction basis. What would we expect to
see at the end of treatment? One such retrospective study has addressed these issues by
analysing the impact of extractions on the lip
morphology in borderline Class II Division 1
malocclusions. In the extraction group where
four first premolars were removed the lower
incisors were on average 2 mm posterior and the
lower lip 1.2 mm posterior when compared with
a non-extraction group. It was seen that the
non-extraction group had 2 mm fuller profile,
although both groups were happy with their
aesthetic appearance.19
Clinicians tend to be very critical about the
changes, both in terms of the hard and soft tissues, which are brought about as a result of
orthodontic treatment whether or not extractions have been carried out. Therefore the general public's perception about the profile of our
patients after treatment should be given some
thought. A timely and relevant study of the
public's perception of the changes in profile of
patients treated for a Class II Division 1 malocclusion concluded that they preferred the profile
changes more in the extraction group compared
with the non-extraction group. There was no
preference for the profiles for either group two
years after treatment.20 It would seem then that
there is no evidence to suggest that extraction
based treatment when prescribed correctly
damages faces.
Summary of extracting teeth and

damaged faces
No evidence to suggest that extracting
teeth in appropriate cases causes a
dished in appearance
Lay opinion finds both extraction and
non-extraction treatment equally
pleasing
SHOULD WE EXTRACT SECOND MOLARS AS

PART OF ORTHODONTIC TREATMENT?
There are said to be many advantages in extracting second molars as part of orthodontic treatment. These advantages include the following:
Less detrimental to facial profile
Facilitates the eruption of third molars
Spontaneous relief of crowding in the premolar region
Prevents crowding in a well aligned lower
arch
Aids distal movement of the buccal segments
with extra oral traction
Shorter treatment time
Functional occlusion is better
It can be seen that it is an impressive list of
advantages! There are however several considerations that need to be taken into account before
extracting second molar teeth with radiological
evaluation of third molar development essential.
All third molars should be present, and have
good size, shape and position.
The idea that extracting second molars is less
detrimental to the facial profile is an interesting
concept, given that the tooth to be extracted is in
a more posterior position in the mouth compared with premolar teeth and is therefore
thought less likely to adversely affect soft tissue
profile. One study investigated this claim by
comparing the effects of different extraction
patterns on the facial profile between two
groups, those treated by first premolar extraction and those by second molar extraction. They
found the average decrease in the soft tissue
angle of facial convexity of 1.7 for the second
molar extraction group and 2.2 for the first premolar group. However, these reductions were
not statistically significant and it must be
remembered that these patients were not derived
from the same population, as they were not randomised to one of the extraction patterns.21
The ideal time for extracting second molars
is controversial, some studies have suggested
the best time to extract them is when the third
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PRACTICE
molar crown is fully formed and others claim
they should be extracted as soon as they erupt
into the mouth. The evidence suggests that the
importance of timing second molar extractions
is not yet known. One disadvantage of extracting second molars is the predictably unpredictable nature of third molar development
and eruption. A number of studies have shown
that third molar eruption is often unsatisfactory,
including improper angulation and contact
relationship with the first molar. This is seen
ranging from 425% of cases22 and raises
doubts on the length of treatment time for second molar extraction cases compared with other
extraction strategies. The loss of second molar
teeth obviates the need for space closing
mechanics but a second course of treatment
may be required to orthodontically upright
third molars at a stage in late adolescence when
co-operation may not be at its best.
An important reason for elective extractions
in orthodontics is the relief of crowding. First
premolar teeth are ideally located as they provide up to 14 mm of space for the relief of
crowding both anteriorly and posteriorly to the
extraction site. Second molar teeth can provide
some 1822 mm of space, of which little is made
available to the relief of crowding in the lower
labial segment where crowding most often
occurs. Given that arch length deficiencies
rarely exceed 10 mm the removal of a second
molar tooth and the space it provides seems a little excessive. However, if the premolar region is
crowded by 45 mm then the removal of second
molar teeth may provide sufficient space for
spontaneous relief of premolar crowding. The
relief of molar crowding in the early permanent
dentition is an indication to extract second
molars and it may also prevent late lower arch
crowding.23
Many of the advantageous claims made for
the extraction of second molar teeth are unsubstantiated. There is no evidence to suggest that
treatment times are shorter, that distal movement of the first maxillary molar is enhanced
and that there is less effect on the soft tissue
profile. The benefits of extracting second
molars appear to be relief of mild premolar
crowding in the early permanent dentition but
eruption of the third molar needs careful
review and the possibility of a later additional
course of orthodontic treatment needs to be
made clear to the patient.
Summary on the extraction of second

molars
Many of the claimed advantages are
unsubstantiated
Evidence suggests relief of molar and
premolar crowding is an indication
Third molar development is predictably
unpredictable and may need further
treatment to orthodontically upright
them
THE ORTHOPAEDIC EFFECT

CAN WE INFLUENCE GROWTH?
The potential to influence growth, whether it is
promoting growth in a Class II malocclusion or
restricting growth in a Class III malocclusion,
remains an area of significant controversy.
A number of studies have looked into the possibility of modifying growth with orthopaedic
appliances and the results are liberally interpreted to suit the position of the challenger. An
orthopaedic effect is taken to mean a change in
the position of the cranio-facial skeleton in relation to each other as the result of orthodontic
treatment. This change should be permanent in
its amount and direction.
Functional appliances have been used for
many years for the correction of Class II malocclusions. Despite this long history there continues to be much debate relating to their use, mode
of action and effectiveness. Undoubtedly, normal dentofacial growth has a genetic drive but
may be influenced by environmental factors.
There is no doubt that functional appliances can
rapidly correct Class II malocclusion but this
does not indicate or prove an orthopaedic
effect.
Some practitioners like to claim they can
grow mandibles, but what is the evidence?
Many studies find an increase in mandibular
length of 12 mm per annum during active
treatment.24 Much of the work demonstrating
the ability of functional appliances to stimulate
mandibular growth is based on animal experimentation. A maximum of 515% increase in
mandibular length by stimulating condylar
growth can be expected in experimental animals
under controlled conditions and during periods
of active growth.25 Animal experimental
research is often cited as evidence but cautious
interpretation of the results is required before it
is applied to patients.
There is evidence from prospective randomised controlled trials that the effects of functional appliances may be transient, with reversion to pretreatment growth patterns over the
short or long term.26 Therefore this short-term
growth enhancement is useful to correct incisor
and molar relationships but does not result in a
longer mandible. They produce their effects
mainly by dentoalveolar changes such as retroclination of upper incisors and proclination of
the lower incisors.27
An orthopaedic change has also been
attempted in Class III malocclusions where it is
largely assumed that the fault lies with a prognathic mandible. Hence chin cup treatment,
once popular, was directed at restraining further
mandibular growth and allowing maxillary
growth to catch up and therefore correct the
anterioposterior component of a Class III malocclusion. A long-term study looking at the effect of
chin cup therapy found that it was effective in
reducing mandibular prognathism before puberty
but this was then lost after puberty ie a shortterm gain similar to that seen with functional
appliances. Indeed, there was no difference in
The orthodontist's
ability to influence
facial growth is
limited and much of
the change that is
seen relates to dento
alveolar changes
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the final skeletal profile of the mandible between
treatment groups and control groups who did
not receive treatment.28
However, there appears to be a promising
method of achieving an orthopaedic effect with
the use of protraction headgear. Several workers
have shown that a small but significant anterior
movement of the maxillae using protraction
headgear during the mixed dentition is possible
which has remained stable some 2 years after
treatment.29
In summary, orthodontic appliances that
deliver an orthopaedic effect may induce a temporary improvement in the skeletal relationship.
There is no evidence at present to show that
orthodontic treatment can effectively restrain or
enhance cranio-facial growth that is otherwise
inherited by the individual.30
9.
10.
11.
12.
13.
14.
15.
16.
Summary of the current evidence on the

orthopaedic effect
Orthodontic treatment cannot influence
growth in the long term
Any gain is small but is often lost in the
long term
Majority of the orthopaedic effect is
dentoalveolar tipping of the teeth
17.
18.
19.
20.
We have chosen four areas of smouldering

controversy, not to rekindle historic arguments
or generate a new turf war but to illustrate the
somewhat flimsy evidence both sides of an argument can use. Forceful opinion currently dominates any cautious interpretation of the existing
literature. Given time, the quality of the data and
research will improve and as a consequence
more definitive statements on true effects of
treatment will be possible.
1.
2.
3.
4.
5.
6.
7.
8.
148
Haynes R B, Richardson W S. Evidence based medicine: what

it is and what it isn't. Br Med J 1996; 312: 71-72.
Richards D, Lawrence A. Evidence based dentistry. Br Dent J
1995; 179: 270-273.
Harrison J E. Ashby D. Orthodontic treatment for posterior
crossbites (Cochrane Review). Cochrane Database Syst Rev
2001; 1: CD000979.
Burke S P, Silveira A M, Goldsmith L J, Yancey J M, Van
Stewart A, Scarfe W C. A meta-analysis of mandibular
intercanine width in treatment and postretention. Angle
Orthod 1998; 68: 53-60.
Proffit W. Contemporary Orthodontics. 3rd ed. St Lewis:
Mosby-Year book, 1999.
Witzig J W, Spahl T J. The clinical management of basic
maxillofacial orthopaedic appliances. Vol 2 Diagnosis.
pp221-224. Boston: PSG Publishing, 1987.
Roth R. Temporomandibular pain-dysfunction and occlusal
relationships. Angle Orthod 1973; 43: 136-153.
Ren Y F. et al. Condyle position in the temporomandibular
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
joint. Comparison between asymptomatic volunteers with

normal disk position and patients with disk displacement.
Oral Surg, Oral Med, Oral Path, Oral Radiol, Endo 1995; 80:
101-107.
Lueke P E, Johnston L E. The effect of first premolar
extraction and incisor retraction on mandibular positions:
testing the central dogma of functional orthodontics. Am J
Orthod Dentofac Orthop 1992; 101: 4-12.
Gianelly A A. et al. Condylar position and maxillary first
premolar extraction. Am J Orthod Dentofac Orthop 1991; 99:
473-476.
Luther F. Orthodontics and the temporomandibular joint:
Where are we now? Angle Orthod 1998; 68: 295-317.
Bush F M. Malocclusion, masticatory muscle and
temporomandibular joint tenderness. J Dent Res 1985; 64:
129-133.
DiPetro G J. A study of occlusion as related to the Frankfortmandibular plane angle. J Prosthetic Dent 1977; 38: 452458.
Andrews L F. The six keys to normal occlusion. Am J Orthod
1972; 62: 296-309.
Kattner P F, Schneider B J. Comparision of Roth appliance
and standard edgewise appliance treatment results. Am J
Lloyd T G, Stephens C D. Changes in molar occlusion after
extraction of all first premolars: A follow up study of Class II
division 1 cases treated wth removable appliances. Br J Ortho
1990; 6: 91-94.
Little R M. An evaluation of changes in mandibular anterior
alignment from 10 to 20 years postretention. Am J Orthod
1988; 93: 423-428.
James R D. A comparative study of facial profiles in
extraction and nonextraction treatment. Am J Orthod
Dentofac Orthop 1998; 114: 265-276.
Paquette D E et al. A long term comparison of nonextraction
and premolar extraction edgewise therapy in borderline
Class II patients. Am J Orthod Dentofac Orthop 1992; 102:
1-14
Bishara S E., Jakobsen J R. Profile changes in patients treated
with and without extractions: Assessments by lay people. Am
J Orthod Dentofac Orthop 1997; 112: 639-644.
Staggers J A. A comparison of second molar and first
premolar extraction treatment. Am J Orthod Dentofac Orthop
1990; 98: 430-436.
Gooris C G M. et al. Eruption of third molars after second
molar extractions: A radiographic study. Am J Orthod
Richardson M E. Lower molar crowding in the early
permanent dentition. Angle Orthod 1985; 55: 51-57.
Lagerstrom L. Dental and skeletal contributions to occlusal
correction in patients treated with high pull headgearactivator combination. Am J Orthod Dentofac Orthop 1990;
97: 495-504.
McNamara J A. Skeletal and dental changes following
functional regulator therapy on class II patients. Am J Orthod
1985; 88: 91-110.
De Vincenzo J P. Changes in mandibular length before,
during and after successful orthopaedic correction of Class II
malocclusion using a functional appliance. Am J Orthod
Bishara S E. Functional Appliances: A review. Am J Orthod
Suagawara J. Long term effects of chincap therapy on
skeletal profile in mandibular prognathism. Am J Orthod
Ngan P. Cephalometric and occlusal changes following
maxillary protraction and expansion. Eur J Orthod 1998; 20:
237-254.
Chate R A. The burden of proof: a critical review of
orthodontic claims made by some general practitioners. Am J
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IN BRIEF
The extraction of teeth for orthodontic purposes has always been a controversial area. It is
not possible to treat all malocclusions without taking out teeth
Where extractions are indicated, first premolars are most commonly extracted but there are
reasons for extracting elsewhere in the arch and this will involve other teeth
The use of fixed appliances has considerably changed extraction viewpoints
8
VERIFIABLE
CPD PAPER
Orthodontics. Part 8: Extractions in orthodontics

H. Travess1, D. Roberts-Harry2 and J. Sandy3
NOW AVAILABLE
AS A BDJ BOOK
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
1Senior Specialist Registrar in Orthodontics;


Dental School, Lower Maudlin Street, Bristol
BS1 2LY; 2*Consultant Orthodontist,
Orthodontic Department, Leeds Dental
Institute, Clarendon Way, Leeds LS2 9LU
Refereed Paper
doi:10.1038/sj.bdj.4810979
195203
Extractions in orthodontics remains a relatively controversial area. It is not possible to treat all
malocclusions without taking out any teeth. The factors which affect the decision to extract
include the patient's medical history, the attitude to treatment, oral hygiene, caries rates and
the quality of teeth. Extractions of specific teeth are required in the various presentations of
malocclusion. In some situations careful timing of extractions may result in spontaneous
correction of the malocclusion.
The role of extractions in orthodontic treatment
has been a controversial subject for over a century. It is fair to say that even today, opinion is
divided on whether extractions are used too frequently in the correction of malocclusion.
Angle1 believed that all 32 teeth could be
accommodated in the jaws, in an ideal occlusion
with the first molars in a Class I occlusion, ie
with the mesiobuccal cusp of the upper first
molar occluding in the buccal groove of the
lower first molar. Extraction was anathema to
his ideals, as he believed bone would form
around the teeth in their new position, according
to Wolff's law.2 This was criticised in 1911 by
Case who believed extractions were necessary in
order to relieve crowding and aid stability of
treatment.3
Two of Angle's students at around the same
time but in different countries considered the
need for extractions in achieving stable results.
Tweed became disappointed in the results he was
achieving and decided to re-treat a number of
patients who had suffered relapse following
orthodontic treatment (at no further cost) using
extraction of four premolar units.4
The demonstration of his results to the profession in America resulted in a change of philosophy in the 1940s to extraction-based techniques.
Begg, in Australia, studied Aboriginal skulls and
noted a large amount of occlusal and more
importantly interproximal wear.5 He argued that
premolar extractions were required in order to
compensate for the lack of interproximal wear
seen in the modern Australian dentition,
through lack of a coarse diet. He also developed
a technique that relied on extractions to create
much of the anchorage needed for treatment.
Recently, the extraction debate has reopened,

with some individuals believing that expansion
of the jaws and retraining of posture can obviate
the need for extractions and produce stable
results. These claims are for the most part unsubstantiated. If teeth are genuinely crowded as
opposed to being irregular then arch alignment
can be achieved by one of the following:
Enlargement of the archform
Reduction in tooth size
Reduction in tooth number
Arch expansion can be achieved by moving
teeth buccally and labially (ie lateral and anterio
posterior expansion) but the long-term stability
and whether bone grows as teeth are moved
through cortical plates remain contentious
issues. In the maxilla there is a suture which
remains patent in some patients into the second
decade. This can also be used in expansion in
that it can be split with rapid maxillary expansion. The split suture fills in with bone and thus
a wider arch to accommodate teeth is created.
There is no good evidence that this method of
expansion produces a more stable result than
any other method. Longitudinal studies provide
useful guidance on whether arch expansion
produces stability. These are difficult studies to
conduct but increasing mandibular length to
accommodate teeth relapses in nearly 90% of
cases with resulting unsatisfactory anterior
tooth alignment.6
Reduction in tooth size, particularly in the
labial segments with interdental stripping, is
another potential mechanism to relieve crowding. Variable relapse has been reported but one
study noted relapse of some degree in all cases.7
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This work was done over 25 years ago and does
not reflect contemporary use of inter-dental
enamel reduction or current retention regimes.
The reduction in tooth number is usually
achieved with extractions and these cases ideally
need to be compared with treated non extraction
cases with spacing, cases treated by arch expansion to accommodate crowding and untreated
normal occlusions. In a review of these issues it
was concluded that arch length reduces in most
cases, including untreated normal occlusion.
Any lateral expansion across the mandibular
canines decreases after treatment but this is also
seen in those cases which have no orthodontic
treatment. It was further recognised that
mandibular anterior crowding is a continuing
phenomenon seen in patients into the fourth
decade and likely beyond.8 The degree of anterior crowding seen at the end of retention is variable and unpredictable.
Proffit9 in a 40-year review of extraction patterns showed 30% of cases were treated with
extractions in 1953, 76% in 1968 and 28% in
1993. He suggested the decline in extractions
since 1968 was because of concern over facial
profile, tempromandibular joint dysfunction
(TMD) and stability; the change from the Begg
appliance, largely an extraction-based technique
to the straight wire technique, which seems to
require fewer extractions. The latter may also
result with a change in mindset and the use of
headgear and prolonged retention.
A dogmatic approach is inadvisable and
each case must be assessed on its merits. Some
cases, especially where the crowding is mild
may not need tooth removal, and a more sensible approach based on the requirements of the
individual case rather that the two extremes
seen in the past century is advised. Interestingly, in a follow up study over a 15 year period in
Fig. 1 Illustration of a macrodont tooth in the lower labial segment, which also exhibits
a talon cusp. Alignment and arch co-ordination is hindered by the size of the tooth and
the talon cusp. Some enamel reduction can be undertaken to reduce the width of the
tooth but care must be taken not to breach the enamel. In the upper arch, reduction of
a talon cusp can help correct an increased overjet, although radiographic examination
of pulp chambers in the talon cusp is essential
196
Scotland, orthodontics replaced caries as the

commonest reason for extraction in patients
under 20 years of age.10 All extractions are
traumatic as far as the patient is concerned and
clinicians will seek non-extraction solutions
where possible. In the late mixed dentition,
between 3 mm and 4 mm of space can be preserved in the lower arch by simply fitting a lingual arch. If this is coupled with molar and premolar expansion of just 2 mm (with no lower
canine exapansion) and interdental enamel
reduction between anterior contact points then
a large proportion of otherwise crowded cases
can be treated without the loss of permanent
teeth. The decision on whether or not to extract
teeth is based on an assessment of many factors
including crowding, increase in overjet, change
in arch width, curve of Spee, anchorage
requirements and other more esoteric factor
such as adjusting the torque of the anterior
teeth. It is also worth mentioning that the concept of space analysis is probably underused in
the United Kingdom, but this is routinely
applied elsewhere. This analysis enables a
rationale and methodical approach to treatment
planning before extractions are recommended.11 It is important then to realise that there are
a variety of options as far as mild to moderate
crowding cases are concerned.
FACTORS AFFECTING THE DECISION TO EXTRACT

It is important to consider the patient as a whole
in treatment planning. Medical history, attitude
to treatment, oral hygiene, caries rate and the
quality of the teeth are important. Patients with
cardiac anomalies are at risk of complications
during orthodontic treatment and consultation
with a cardiologist is important. If necessary,
extractions should be covered with appropriate
antibiotics and impacted teeth may be best
removed rather than aligned as traction to
unerupted teeth may pose an increased risk to
these patients.12
The quality and prognosis of the teeth should
be carefully considered, as this may override
other factors. Hypoplastic, heavily restored or
carious teeth should generally be removed in
preference to healthy teeth. This is especially true
in the labial segments where aesthetics are difficult to maintain with loss of an incisor or canine.
Teeth of abnormal form or size may be considered for removal as they can look unsightly
and be difficult to align. For example, a dens-indente may compromise the long-term prognosis
of a tooth, or a talon cusp may hinder arch
co-ordination during treatment. Dilacerated
teeth should be carefully assessed to see if crown
alignment is achievable. Often extraction of
these teeth is the only option. Macrodont teeth,
geminated or fused, need careful consideration
(Fig. 1). The aesthetics are often poor but extraction can result in an excess amount of space,
which may prolong orthodontic treatment.
Where supplemental teeth are present, extraction may result in spontaneous correction of any
crowding (Fig. 2).
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EASE OF EXTRACTION, AND THE PRESENCE OF
IMPACTED TEETH
The extraction of teeth is a potentially traumatic
experience. The decision to extract should be
made with an awareness of the risks of treatment, including the psychological impact of the
procedure. The General Dental Council in its
guidance to dentists of professional and personal
conduct makes it clear that dentists who refer
patients for general anaesthesia must make it
clear what justification there is for the procedure. The duties of the treating dentist include a
thorough and clear explanation of the risks
involved as well as the alternative methods of
pain control available. The use of general anaesthesia is usually considered in dealing with
unerupted teeth, first molars, multiple extractions in four quadrants and specific phobias.
If teeth are impacted or ectopically positioned, extraction of an erupted tooth can guide
the path of eruption of the impacted tooth and
obviate the need for minor oral surgery. For
example, the impaction of a lower second premolar may be relieved by the removal of the first
premolar or first molar, which only requires
local analgesia and is less traumatic than the
removal of the impacted tooth (Fig. 3). In
Figure 4, eruption of the upper second premolars
resulted in severe resorption of the roots of the
upper first molars. Extracting these molars
would be fairly atraumatic and allow the second
premolars to erupt into the mouth. Similarly, if
unerupted permanent canines are palatally positioned judicious removal of the deciduous
canines can improve the path of eruption of the
permanent teeth and may help to avoid lengthy
orthodontic treatment.13
CORRECTION OF OVERBITE
Space closure with fixed appliances tends to
increase the overbite and therefore extractions
in the lower arch in deep bite cases should be
undertaken with caution. In some malocclusions, where the anterior face height is reduced,
extractions can make space closure difficult and
great care must be taken in diagnosis before this
decision is made. It is important to recognise
whether a case is genuinely crowded or whether
the teeth are displaced lingually as in a Class II
Division 2 case. Lingually displaced lower labial
segments are frequently not crowded, even
though they may appear to be so.
Proclination of the lower labial segment also
reduces the overbite, as well as overjet, and may
obviate the need for extractions. However, this
treatment approach should be undertaken cautiously as uncontrolled and excessive proclination of the lower incisors can be unstable and
should only be undertaken in selected cases by
experienced clinicians. Flattening of an accentuated curve of Spee in order to reduce an overbite, where proclination is contraindicated, does
require space, for which the extraction of lower
teeth can sometimes be considered. The space
required to flatten a curve of Spee has historically
been over rated, the amount of space required is
Fig. 2 A supplemental lower incisor (a) was removed,

resulting in spontaneous correction of crowding in
the lower labial segment (b)
Fig. 3 This case presented with missing upper first premolars and lower right
third molar, with vertically impacted lower second premolars. (a) Both lower
first molars are heavily filled and would be ideal for extraction to allow
eruption of the second premolars. However the missing third molar on the
right resulted in extraction of the lower right first premolar and the lower
left first molar. Spontaneous alignment occurred (b) with both impacted
premolars erupting successfully into the occlusion with no active treatment
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c
Fig. 4 In this case, the erupting upper
second premolars showed some resorption
of the mesial roots of the upper first
molars. (a) Progressive resorption of the
mesial roots of the molars was seen on
subsequent radiographs (b), which
progressed to such an extent (c) that both
upper first molars required extraction,
allowing eruption of the second premolars
12 mm when the curve is severe and there is no

crowding. It is difficult then to justify extracting
teeth purely for the sake of creating space to
flatten an occlusal curve. The greatest challenge
is the mechanical control of the teeth to prevent
excessive proclination of the lower incisors. This
usually occurs because the intrusion force is at
some distance labial to the centre of resistance
of the incisors and lingual crown torque is needed to prevent the labial movement of the incisors.
EXTRACTION OF SPECIFIC TEETH

Despite the factors discussed above, certain teeth
are extracted preferentially for orthodontic reasons. A survey of extraction patterns in the hospital orthodontic service (Table 1) showed that
first premolars were most commonly extracted
(59%) followed by second premolars (13%). Permanent molars accounted for 19% of extractions
(12% for first molars and 7% for second molars).
Only 1% of patients had incisor extractions.14
The high percentage of premolar extractions
is related to their position in the arch and the
Table 1 Table of percentage extractions according to
tooth type
Tooth
Central incisor
Lateral incisor
Canine
First premolar
Second premolar
First molar
Second molar
198
% removed
1
3
4
59
13
12
7
timing of their eruption. They are often ideal for

the relief of anterior and posterior crowding.
However, each patient should be seen as an individual and their treatment planned according to
the merits of the malocclusion,
Lower incisors
In general, removal of a lower incisor should be
avoided, as the inter-canine width tends to
decrease which can result in crowding developing in the upper labial segment or the overjet
increasing. However, a number of situations do
exist in which a lower incisor may be considered
as part of an orthodontic treatment plan and
fixed appliances are generally required in these
cases. These include situations where a lower
incisor is grossly displaced from the arch form or
'ectopic' and space is required to align the teeth.
This is best considered in adults and especially
those who have had previous loss of premolar
units in each quadrant and present with late
lower labial segment crowding (Fig. 5). Class III
cases at the limit of their growth can be camouflaged with loss of a lower incisor, to allow the
lower labial segment to be tipped lingually, correcting the incisor relationship. This also tends
to increase the overbite, which is helpful in these
cases.15 Treatment of Class I cases with moderate
lower labial segment crowding of up to 5 mm (ie
the size of a lower incisor) may be treated with
loss of a lower incisor. An increase in overjet or a
slightly Class III buccal segment relation may be
an undesirable side effect.16 Cases where a tooth
size discrepancy exists, for example with upper
peg shaped laterals or missing upper lateral incisors may also benefit from the loss of a lower
incisor. A Bolton analysis (a measure of tooth
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PRACTICE
size discrepancies) may be used to analyse the
extent of the disproportion. A Kesling set up17
(where the anterior teeth are sectioned from a
plaster model and re-positioned in wax as a trial
set up, having left out a lower incisor) may be
helpful in predicting the final outcome (Fig. 6).
Upper Incisors
Upper incisors are rarely the extraction of choice
to treat a malocclusion. However, the upper labial
segment is particularly at risk from trauma,
especially in Class II Division 1 cases with large
overjets. In situations where the long-term prognosis of an incisor is poor, for example, the incisor is non vital, root filled, dilacerated or of
abnormal form, the tooth should be considered
for extraction as part of the orthodontic treatment plan. Full consideration should be given to
the resulting occlusion and aesthetics. Placing a
lateral incisor in a central incisor position rarely
gives a good result because the root of the tooth
is narrow and the emergence angle of the built
up crown is poor. In some cases transplantation
of a premolar with a developing root into the
incisor socket can relieve crowding in the lower
arch and provide a useful replacement in the
upper labial segment (Fig. 7).
Where lateral incisors are diminutive or
missing, space closure or space maintenance
can be considered more equally. Attention
must be paid to the shape, size, gingival height
and colour of the canine if a good aesthetic
result is to be achieved. In many cases the
canines can be disguised as lateral incisors by
selective grinding, and where appropriate, aesthetic build-ups.
b
Fig. 5 Premolars had
previously been extracted as
part of orthodontic
treatment in adolescence.
Crowding returned in the
lower labial segment (a),
which was relieved by
removal of a lower incisor
and fixed appliance
treatment. A bonded retainer
was fitted at the completion
of treatment (b)
Canines
These teeth are rarely considered for extraction
unless very ectopic (Fig. 8). The loss of a canine
makes canine guidance impossible and may
compromise a good functional occlusal result.
Contact between a premolar and lateral incisor is
often poor and canines can act as ideal abutment
teeth because of their long root length and resistance to periodontal problems. Palatally ectopic
canines can sometimes be in unfavourable positions for alignment, and lower ectopic canines
often require extraction rather than alignment.
In many of the former cases the first premolar
can be aligned with a mesial inclination and
rotated mesio-palatally to hide the palatal cusp
and provide a better aesthetic result.
Premolars
Premolars are often ideal for the relief of both
anterior and posterior crowding, the first and
second premolars have similar crown forms,
which means that an acceptable contact point
can be achieved between the remaining premolar and the adjacent molar and canine. The
choice between first or second premolar depends
on a number of factors: for example, the degree
of crowding, the anchorage requirements, the
overjet and overbite.
In Class I cases where crowding exists and the
Fig. 6 A Kesling set up of the

case in Figure 5, removing the
lower left central incisor and
replacing the remaining incisors
and canines.
This showed the anticipated
tooth positions and occlusion
with the upper arch
Fig. 7 A lower premolar

has been transplanted
to replace the upper
left central incisor
which had a poor
prognosis
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PRACTICE
c
d
Fig. 8 A severely
crowded case, where
unusually, four canines
were extracted. The
resulting occlusion
gave acceptable
contacts between first
premolar and lateral
incisors and improved
the arch form.
(a-c) Pre treatment,
(d-f) Post treatment
canines are mesially angulated, loss of first premolars may produce spontaneous improvement
in the alignment of the canines (Fig. 9). Any
excess extraction spaces may close with time,
although a study by Berg et al., showed space
closure to be greatest in the first 6 months following extraction.18 In carefully selected cases
reasonable alignment can sometimes be
achieved. However cases amenable to this type
of treatment are rare and fixed appliances especially when second premolars have been
extracted invariably produce better results.
Second premolars are the third most commonly developmentally absent teeth after third
molars and upper lateral incisors.19 Where
deciduous molars are retained beyond their normal exfoliation dates, a radiograph should be
taken to confirm the presence and position of
the permanent successor. In uncrowded arches
deciduous molars with good roots are often
retained, as space closure in these cases can be
difficult (Fig. 10).
Second premolars can become impacted
either due to early loss of deciduous molars or
severe crowding. Ectopic second premolars usu200
ally erupt lingually or palatally and should be

considered for extraction if they are completely
excluded from the arch (Fig. 11).
First molars
First permanent molars are often the first permanent teeth to erupt into the mouth. Their deep
fissure morphology predisposes them to caries
and poor tooth brushing combined with a high
sugar intake, may result in gross caries. Heavily
restored or decayed first molars should be considered for removal over other non-carious teeth
(Fig. 12). First molars extraction requires careful
planning. Their position in the arch means that
whilst relief of premolar crowding is achieved
the space created is far from the site of any incisor crowding or overjet reduction. The timing of
the loss of first molars is also an important consideration.
Maxillary second molars have a curvilinear
eruptive path with mesial and vertical components. The lower second molar has a more vertical path, but it has to move more horizontally in
favourable spontaneous molar correction. This is
one of the reasons why the spontaneous tooth
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Fig. 9 A Class I case

with mild lower labial
segment crowding in
the late mixed
dentition (a) & (b). All
four first premolars
were extracted and the
occlusion allowed to
align spontaneously.
(c) & (d)
second premolar. Spontaneous relief of mild

crowding in the labial segments may be seen. In
the lower arch, spontaneous closure is less likely,
but mesial migration of the second molar is also
optimal at this stage and may resulting in minimal space between the second molar and second
premolar (Fig. 12).
In the permanent dentition the effect of loss
of a first molar can be difficult to predict after
the second molar has erupted. Fixed appliances
are invariably needed at this stage to align the
teeth and achieve space closure with parallel
roots.20 The effects are more of a problem in the
lower arch, where the second molar tips mesially and rolls lingually forming a very poor contact with the second premolar or may leave
excess space. Little spontaneous relief of anterior crowding is seen. The upper first molar if
retained can over-erupt, further increasing the
tipping and rolling of the lower second molar.
In addition mesial movement of the lower
Fig. 10 A hypodontia case pre-treatment showing

good quality deciduous molars which were
retained as part of the treatment plan. Mesiodistal reduction or 'slenderising' can be used to
maximise arch co-ordination, especially where
deciduous molars are only retained in one arch
movement is less favourable in the lower arch.

Three periods of development can be considered
when looking at the effects of loss of first
molars.
Maximal space closure by mesial migration
of the second molar occurs in the mixed dentition. At this stage the second molars are
unerupted and their root furcation is just calcifying. The best results occur in the upper arch
where the second molar will usually erupt
mesially and make contact with the upper
Fig. 11 Localised crowding often manifests in

the lower buccal segments by lingual eruption
of the second premolar
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Fig. 12 Four first molars were extracted just after the

optimal time, prior to fixed appliance treatment. The
orthopantomogram (a) shows gross caries in the left first
molars and heavy restorations in the right first molars.
Notice the discrepancy in space available in the two arches.
In the upper arch the second molars have erupted in close
proximity to the second premolars due to their mesial
eruptive path (b). In the lower arch there is considerably
more space remaining from the vertical eruptive path of the
second molars (c)
Fig. 13 Extraction of second molars allowed

spontaneous relief of anterior crowding, with early
eruption of the third molars
202
molar may be prevented. The upper second

molar shows less tipping and rolling than its
lower counterpart, but does not align to the
extent seen in the mixed dentition. In adult
patients the drifting of both upper and lower
second molars is less marked, and the relief of
crowding less reliable. In young patients, radiographs should be checked to ensure that the
developing lower second premolar is contained
by the roots of the primary molar. If not, then
substantial drifting of the second premolar can
take place including impaction into the mesial
surface of the second molar.
In general terms if a lower first molar is to
be extracted, the upper molar on the same
side should also be extracted (compensating
extraction). This prevents unwanted overeruption of the upper first molar and the
upper second molar will usually erupt into a
good position. However, if an upper first
molar is to be extracted, the lower counterpart is usually left in situ. This is because the
lower second molar behaves unpredictably
and rarely achieves good spontaneous alignment. An additional factor is that lower
molars over erupt less than upper molars and
will not interfere with the generally good
progress made by upper second molars. If the
case has no crowding, then balancing extractions should not be considered (removal of a
tooth on the opposite side of the same arch).
Children presenting with carious first molars
often show signs of disease in all of them. If
the timing is correct and the malocclusion
justifies treatment, all four first molars
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PRACTICE
should be removed to allow second molars to
erupt efficiently and reduce subsequent
treatment times.
Second molars
Thomas et al.21 provided a succinct summary on
the role of loss of second molars in orthodontic
treatment. They state that all other teeth should
be present with the third molars of normal size,
shape and in a good position to erupt. Mild
lower labial segment crowding may be effectively treated by loss of second molars, however
they should not be considered in the treatment
of moderate or severe crowding. Second molar
loss may be undertaken under the following circumstances:
To facilitate the eruption of the third molars
obviating the need for surgical removal at a
later stage.
To allow relief of premolar crowding (especially where second premolars are impacted)
May prevent crowding in a well-aligned lower
arch (Fig. 13).
Distal movement in the upper arch is more
reliable and more stable.
However, the potential disadvantages of
second molar extraction are:
Eruption of third molars especially in the
lower arch is unpredictable. About 30% of
these teeth require uprighting.
The teeth are remote from the site of crowding
making alignment unpredictable.
Where second molars are considered for
extraction, the timing is important. Satisfactory
third molar alignment is less likely if the second
molars are extracted after the third molar roots
are more than one third formed.
Third molars
Whilst extraction of wisdom teeth for orthodontic purposes is rare, these teeth should be included in the treatment planning. The incidence of
impaction of third molars varies widely in the
literature.22 Posterior crowding, especially in the
lower arch, may increase the risk of developing
impaction. Extraction of teeth towards the front
of the mouth has little effect on posterior crowding, whilst extractions towards the back improve
the chances of acceptable third molars eruption.
The greatest benefit occurs when second molars
are removed, although eruption patterns are
unpredictable. Richardson et al.23 suggest that
up to 90% of third molars erupt into satisfactory
positions following second molar removal, but
this depends on the degree of posterior crowding
and stage of root development of third molars at
time of extraction. It also assumes a fairly broad
minded view of what is a satisfactory position.
Third molars have in the past been implicated
in the aetiology of late lower incisor crowding.23
However, more recent research shows that their
presence is only one of the factors involved and
their influence appears to be negligible. Therefore, third molars should not be removed to
relieve or prevent late lower incisor crowding.24
This forms part of the National Clinical Guidelines on the management of patients with
impacted third molars.22
CONCLUSIONS
Many factors influence the choice of teeth for
extraction and careful treatment planning in
conjunction with good patient co-operation,
appliance selection and management of the
treatment are essential if an acceptable, aesthetic and functional occlusion is to be achieved.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Angle E H. Treatment of malocclusion of the teeth and

fractures of the maxillae, Angle's system. Ed 6, 1900 S.S.
Philadelphia: White Dental Manufacturing Co.
Wolff J. Das Gesetz der Transformation der Knochen. Berlin:
Hirschwald, 1892.
Case C S. The question of extraction in orthdontia. Am J
Orthod 1964; 50: 658-691.
Tweed C. Clinical Orthodontics. 1966, St Louis: Mosby.
Begg P R. Stone age man's dentition. Am J Orthod 1954; 40:
298-312.
Little R M, Riedel R A, Stein A. Mandibular arch length
increase during the mixed dentition: postretention
evaluation of stability and relapse. Am J Orthod Dentofac
Orthop 1990; 97: 393-404.
Betteridge M A. The effects of interdental stripping on the
labial segments evaluated one year out of retention. Br J
Orthod 1981; 8: 193-197.
Little R M. Stability and relapse of dental arch alignment. Br J
Orthod 1990; 17: 235-241.
Proffit W E. Forty-year review of extraction frequency at a
university orthodontic clinic. Angle Orthod 1994; 64:
407-414.
McCaul L K, Jenkins W M, Kay E J. The reasons for extraction
of permanent teeth in Scotland: a 15-year follow-up study.
Br Dent J 2001; 190: 658-662.
Kirschen R H, O'Higgins E A, Lee R T. The Royal London Space
Planning: an integration of space analysis and treatment
planning: Part II: The effect of other treatment procedures on
space. Am J Orthod Dentofacial Orthop 2000; 118: 448-461.
Khurana M, Martin M V. Orthodontics and infective
endocarditis. Br J Orthod 1999; 26: 295-298.
Ericson S, Kurol J. Early treatment of palatally erupting
maxillary canines by extraction of the primary canines. Eur J
Orthod 1988; 10: 283-295.
Bradbury A J. The influence of orthodontic extractions on the
caries indices in schoolchildren in the United Kingdom.
Comm Dent Health 1985; 2: 75-82.
Canut J A. Mandibular incisor extraction: indications and
long-term evaluation. Eur J Orthod 1986; 18: 485-489.
Graber T M. New horizons in case analysis: clinical
cephalometrics. Am J Orthod 1956; 53: 439-454.
Tuverson D L. Anterior interocclusal relations. Part II. Am J
Orthod 1980; 78: 371-393.
Berg R, Gebauer U. Spontaneous changes in the mandibular
arch following first premolar extractions. Eur J Orthod 1982;
4: 93-98.
Vastardis H. The genetics of human tooth agenesis: new
discoveries for understanding dental anomalies. Am J Orthod
Sandler P J, Atkinson R, Murray A M. For four sixes. Am J
Thomas P, Sandy J R. Should second molars be extracted?
Dent Update 1995; 22: 150-156.
National Clinical Guidelines. The management of patients
with impacted third molar (syn. Wisdom) teeth. Royal College
of Surgeons of England 1997.
Richardson M E, Richardson A. The effect of extraction of
four second permanent molars on the incisor overbite. Eur J
Orthod 1993; 15: 291-296.
Schwarze C W. The influence of third molar germectomy - a
comparative long term study. Abstract of Third International
Congress, London 1973; 551-562.
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IN BRIEF
Anchorage is the resistance to unwanted tooth movement

It can be obtained from a number of different sources
Loss of anchorage can have a detrimental effect on treatment
Safety is of prime importance when using extra-oral devices
Orthodontics. Part 9: Anchorage control and

distal movement
Anchorage is an important consideration when planning orthodontic tooth movement.
Unwanted tooth movement known as loss of anchorage can have a detrimental effect on
the treatment outcome. Anchorage can be sourced from the teeth, the oral mucosa and
underlying bone, implants and extra orally. If extra-oral anchorage is used, particularly with
a facebow then the use of at least two safety devices is mandatory.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
1*Consultant Orthodontist,
Orthodontic
Clarendon Way, Leeds LS2 9LU;
Bristol BS1 2LY;
Refereed Paper
doi:10.1038/sj.bdj.4811031
255263
Anchorage is defined as the resistance to

unwanted tooth movement. Newton's third law
states that every action has an equal and opposite
reaction. This principle also applies to moving
teeth. For example, if an upper canine is being
retracted, the force applied to the tooth must be
resisted by an equal and opposite force in the
other direction. This equal and opposite force is
known as anchorage.
Anchorage may be considered similar to a tug
of war. Two equal sized people will pull each
other together by an equal amount. Conversely a
big person will generally pull a small one without
being moved. However, if two or more smaller
people combine then their chances of pulling a
big person will increase. Similarly, the more
teeth that are incorporated into an anchorage
block, the more likely it is that desirable as
opposed to undesirable tooth movements will
occur. Undesirable movement of the anchor
teeth is called loss of anchorage.
If an upper canine is to be retracted, with bodily movement using a fixed appliance, the force
applied to the tooth will be approximately 100 g
(Fig. 1a). Forces in the opposite direction varying
from 67 g on the first permanent molar to 33 g
on the upper second premolar resist this. Low
levels will produce negligible tooth movement
and the effect of a light force of 100 g would be
to retract the canine with minimal anterior
unwanted movement of the anchored teeth.
However, if the force level is increased to say
300 g (Fig. 1b), the force levels on the anchor
teeth increase dramatically to the level where
unwanted tooth movements will occur.
Although the canine may move a little distally,
BRITISH DENTAL JOURNAL VOLUME 196 NO. 5 MARCH 13 2004
the buccal teeth will also move mesially. Space

for the canine retraction may be eliminated with
insufficient space left for alignment of the anterior teeth. Figure 1c compares the root area of
some of the upper teeth. The combined root area
of the upper incisors and upper canines is
around the same as that of the first molar and
premolars. Therefore, if the upper labial segment
including the upper canines is retracted in a
block, there will be an equivalent mesial movement of the upper molar and upper premolar.
These factors need to be very carefully considered in planning anchorage requirements and
tooth movement.
Anchorage may be derived from four sources:
Teeth
Oral mucosa and underlying bone
Implants
Extra oral
TEETH
The anchorage supplied by the teeth can come
from within the same arch as the teeth that are
being moved (intra maxillary) or from the
opposing arch (inter maxillary).
Intra maxillary anchorage
The anchorage provided by teeth depends on the
size of the teeth, ie the root area of the teeth. Fig.
1c shows the root surface area of each of the
teeth in the upper arch. The more teeth that are
incorporated into an anchorage block the less
likely unwanted tooth movement will occur.
If a removable appliance is used, the base plate
and retaining cribs should contact as many of
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PRACTICE
the teeth as possible. Figure 2 illustrates the
point. If upper canines are to be retracted with a
removable appliance, cribs on the first permanent molars and upper incisors will not only
help with retention but also increase the
anchorage considerably. In addition, the base
plate must contact the mesial surface of the
upper second premolars and palatal to the
upper incisors. If fixed appliances are to be
used, the more teeth that are bracketed or
banded, the greater will be the anchorage
resistance (Fig. 3).
100g
33g
67g
Fig. 1a A distalising force on the upper canine will produce a reciprocal force in the
opposite direction on the anchor teeth. Provided the force level for bodily movement is
kept low at about 100g then there will be minimal mesial movement of the anchor teeth
300g
100g
200g
Fig. 1b As the distalising force level increases the reciprocal forces also increase with
a greater risk of loss of anchorage
2.2
6.7
1.8
2.7
2.3
6.9
4.6
Fig. 1c The combined root surface area of the anterior teeth is almost the same as
the molar and premolar. Attempting to move all the anterior teeth distally
simultaneously will result in an equal mesial movement of the posterior teeth
256
Inter maxillary anchorage

Teeth in the opposite arch can provide very useful and important sites of anchorage control as
Figs 4a,b illustrate. Good inter-digitation of the
buccal teeth can help prevent mesial movement
of the buccal segment. Although there is only
anecdotal evidence to support this view, many
clinicians feel this can be a useful source of
anchorage.
The second way that opposing teeth can be
used is by means of elastics or springs running
from one arch to the other. Class II elastics
(Fig. 4c) run from the lower molars to the
upper incisor region, whereas Class III elastics
(Fig. 4d) run from the upper molars to the
lower incisor region.
Inter-maxillary elastic are invaluable in
many cases but do rely very heavily on good
patient co-operation. The elastics need to be
changed every day and if they break (which
they frequently do) they must be replaced
immediately. Class II elastics will also tend to
have unwanted effects on the occlusion. They
tend to tip the lower molars mesially and roll
them lingually. In addition, they can produce
extrusion of the upper labial segment and the
lower molars. Whilst extrusion of the lower
molars can help with overbite reduction,
extrusion of the upper incisors is usually an
unwanted side effect and has to be counteracted by adding an upward curve to the upper
arch-wire known as an increased curve of
Spee. Extrusion of the buccal teeth is undesirable in patients with increased lower face
height and therefore Class II elastics should be
used sparingly in these cases. Similarly Class
III elastics can extrude the upper molars, tip
them mesially and roll them palatally. Molar
extrusion will decrease the overbite, which is
usually undesirable in Class III cases. Elastics
also tend to cant the occlusal plane and have
been implicated in root resorption in the upper
labial segment, particularly if they are used
for prolonged periods.
Functional appliances are another source of
intermaxillary anchorage. Whilst some clinicians may believe these devices simply make the
mandible grow, this is not the case and whatever
mandibular growth does take place, is accompanied by quite substantial movement of the dentition over the apical base. This means that mesial
tipping of the lower and distal tipping of the
upper teeth occurs.
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ORAL MUCOSA AND UNDERLYING BONE
Contact between the appliance and the labial
or lingual mucosa can increase anchorage
considerably for either fixed or removable
appliances. Contact between an orthodontic
appliance and the vault of the palate provides
resistance to mesial movement of the posterior
teeth. The anchorage provided by this means
is considerably greater if there is a high vaulted palate as shown in Figure 5a, which will
produce a greater buttressing effect. A shallow
vaulted palate (Fig. 5b) will provide much less
anchorage control because the appliance will
simply tend to slide down the inclined plane
of the palate.
The mucosa and underlying bone can also
be used when fixed appliances are used, for
example a Nance palatal arch (Fig. 5c). This is
an acrylic button that lies on the most vertical
part of the palate behind the upper incisors and
is added to a trans-palatal arch. These buttons
are again of more limited use if the palatal
vault is shallow.
IMPLANTS
Osseo-integrated implants can be used as a
very secure source of anchorage. Implants
integrate with bone and do not have a periodontal membrane. Because of this they do
not move when a force is applied to them and
in some cases they can provide an ideal source
of anchorage. Recently small implants for
orthodontic use have been specifically
designed and can be used in the retro-molar
region to move teeth distally or anteriorly for
mesial movement. Short 4mm implants can be
Fig. 2 Incorporating
as many teeth as
possible in the
appliance design and
covering the anterior
palatal vault will
increase the
anchorage
Fig. 3 When fixed

appliances are used,
as many teeth as
possible are banded to
increase the anchorage
Fig. 4a,b Inter-digitation of the buccal occlusion can help

increase anchorage
Fig. 4c Intermaxillary elastics use teeth in the opposite arch as a

source of anchorage. Class II traction is shown here
Fig. 4d Class III elastics
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PRACTICE
paced in the anterior mid-line of the palate in
the thickest part of the nasal crest and a transpalatal bar then connects the implants to the
teeth (Fig. 6).
EXTRA-ORAL ANCHORAGE
This can be applied via a number of devices
and can be used in conjunction with either
removable or fixed appliances. Headgear is
not a recent invention and has been in use for
over a century. Figure 7a is a picture of a
Kingsley headgear, which was in use as early
as 1861.
The force from the headgear is usually
applied to the teeth via a face-bow (Klen bow)
as shown in Fig. 7b. This is fitted either to tubes
attached to the appliance or integral with it as
in the en masse appliance. The direction by
which the force is applied can be varied
depending on the type of headgear that is
fitted. Headgear can be applied to both the
maxillary and mandibular dentition, and there
are a number of variations:
The most important of these problems is the

fact that headgear can be dangerous and a
number of facial and serious eye injuries have
been reported in the literature.13 The Standards and Safety Committee of the British
Orthodontic Society (BOS) have addressed
these concerns. An advice sheet produced by
the BOS is essential reading for anyone who
wishes to use headgear.4
The main problems with headgear safety
relate to the prongs at the end of the face-bow
that fit into the headgear tubes on the intra-oral
appliance. It is possible for the bow to become
dislodged, either because it is pulled out of the
mouth or when the patient rolls over when they
are asleep. The recoil effect from the elastics can
damage the teeth, oral mucosa, soft tissues of the
face and most seriously, the eyes. In order to
minimise these problem various safety devices
have been suggested. These involve re-curving
the distal end of the wire, using plastic coated
face bows and various locking springs.5,6 In
addition a variety of snap-away face bows have
been produced. If these are pulled beyond a pre
set distance, the neck strap comes apart and prevents any recoil injury. Another popular method
of preventing recoil is to fit a rigid safety strap,
which prevents the bow from coming out of the
mouth if it disengages from the tubes. Some
examples of these safety devices are shown in
Figures 8a-i.
The importance of headgear safety cannot be
over emphasized and it is recommended that two
safety mechanisms are simultaneously used, for
example a locking spring and a snap away headgear or a safety face-bow and rigid safety strap.
Cervical
Occipital
Variable
Reverse
Cervical Headgear
This is applied via an elastic strap or spring,
which runs around the neck (Fig. 8a). It has the
advantage of being relatively unobtrusive and
easy to fit. However, it does tend to extrude the
upper molars and tip them distally because of
the downward and backward direction of force.
This later effect can be counteracted to some
degree by adjusting the height and length of the
outer bow. Cervical headgear should not be
attached to removable appliances because it is
prone to dislodge the appliance and propel it to
the back of the mouth.
Occipital
This is also known as high pull headgear and
is applied via an occipitally placed head-cap
(Fig. 8b). It is easy to fit but is more obvious
than the neck strap and tends to roll off the
head unless carefully adjusted. Because the
force is in a more upward direction, there is
generally less distal tipping of the upper molar
and less extrusion, but also less distal movement than with cervical headgear. The tipping
and extrusion effect again depend on the
length and height of the outer bow.
Variable
This applies a force part way between cervical
and occipital (Fig. 8c) and is our preferred
choice. It takes slightly longer to fit than
either cervical or occipital and is more obtrusive. However it is secure and comfortable and
the vector of the force can be varied to produce relatively less tipping and/or extrusion.
Whilst headgear is a very useful source of
anchorage, it has a number of disadvantages.
These are as follows:
258
Safety
Clinical time
Compliance
Operator preference
Reverse
Reverse or protraction headgear is useful for
mesial movement of the teeth, either to close
spaces or help to correct a reverse overjet. It does
not employ a face-bow, which is an advantage
but instead employs intra-oral hooks to which
elastics are applied (Fig. 9a,b).
LOSS OF ANCHORAGE
This is defined as the unplanned and unexpected
movement of the anchor teeth during orthodontic treatment.
There are several causes of loss of anchorage.
Some examples of these are:
Poor appliance design
Poor appliance adjustment
Poor patient wear
Poor appliance design

Failure to adequately retain the appliance, or
incorporate as many teeth into the anchor block
as possible are common causes of anchorage
loss. If fixed appliances are used, as many
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PRACTICE
Fig. 5a A steep anterior palatal vault is a useful source of

anchorage due to the buttressing effect
Fig. 5c The palatal vault can be used for removable or fixed

appliances. An example of a Nance button is shown here
Fig. 5b A shallow palatal vault provides less anchorage
Fig. 6 An osseo-integrated implant with a bonded

palatal arch is being used to help close space in the
upper arch without retroclining the upper incisors
Fig. 7a An early Kingsley

headgear circa 1860
Fig. 7b,c A facebow

(Klen bow) is attached
to tubes welded to
bands on the molars
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PRACTICE
Fig. 8a A neck strap. Note the snap

away safety mechanism
Fig. 8b An occipital (high pull)

headgear again with a snap away safety
system
Fig. 8c A variable pull Interlandii

headgear. A rigid plastic strip is
employed as a safety mechanism to
prevent the facebow disengaging from
the molar bands and coming out of
the mouth
Fig. 8d,e The end of the

facebow can be re-curved
to improve safety
Fig. 8f,g A plastic coated

facebow together with a
safety neck-strap
Fig. 8h,i A Samuels locking

spring. This secures the face
bow to the tube preventing
accidental disengagement.
This should be used in
conjunction with a safety
neck strap or snap away
headgear
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PRACTICE
anchor teeth as possible should be banded in
order to produce optimum anchorage. Removable appliances should have adequate retention
using appropriate well-adjusted cribs or clasps
with as much contact with the teeth and oral
mucosa as possible.
Poor appliance adjustment

The use of excessive force or trying to move too
many teeth at the same time may result in
unwanted movement of the anchor teeth. To
avoid loss of anchorage, simultaneous multiple
teeth movement should be avoided. If the
appliance is poorly adjusted so that it doesn't
fit very well, or the force levels applied to the
teeth are too high, then undesired tooth movement may occur. High force levels produced by
over activation are one of the key reasons for
anchorage loss.
The optimal force for movement of a single
rooted tooth is about 2540 g for tipping and
about 75 g for bodily movement. If the force is
too low there will be very little movement,
whereas too much force may result in loss of
anchorage. Excess force does not increase the
rate of tooth retraction as illustrated in Fig. 10.7
As the force levels rise the rate of tooth tipping
also increases up to about 40 g. Beyond this very
little extra tooth movement occurs. Thus
increasing the force levels above about 40 g will
not increase the rate of tooth tipping.
The force levels that wires from fixed or
removable appliances exert on teeth usually
depends on the following:
The material the wire is made from

The amount it is deflected
The length of the wire
The thickness of the wire
Steel wire will exert a force that is directly

proportional to the amount the wire is deflected
up to its elastic limit. Figure 11 demonstrates
how decreasing the wire thickness and increasing the length (sometimes by adding loops) controls the force produced.
Modern alloys such as super elastic nickel titanium wires do not act in the same way as steel.
These remarkable wires are capable of producing
Fig. 9a, b A reverse, or protraction headgear
Rate of canine retraction

(mm per month)
1.5
0.5
0
0
10
20
30
40
50
60
gm
Fig. 10 The graph shows how increase force levels do not necessarily increase the
rate of tooth movement. The y axis shows the rate of movement in mm. The x axis
is the amount of tipping force applied to the tooth. As the force level initially rises
the rate of tooth movement also increases. Above about 40 g the rate slows down
and very little additional tooth movement occurs. There will however be a greater
risk of loss of anchorage with increased force levels
0.6 mm
Fig. 11 A 0.5 mm diameter wire can be

deflected more than a 0.6 mm wire
without increasing the force level. Thus a
greater degree of activation is possible
and the appliance will require less
frequent adjustments. Similarly
increasing the length of the wire, for
example by incorporating loops allows a
greater degree of wire deflection. The
force characteristics may also
be changed by altering
the material the wire is made from
0.5 mm
0.5 mm
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PRACTICE
Fig. 12a-c Super elastic heat

activated wires produce a light
continuous force almost regardless
of the amount of deflection. When
cooled they become very flexible
(12a) but return to their original
shape as they warm in the mouth
(12b,c)
a continuous level of force almost independent of

the amount of deflection and have transformed
the use of fixed appliances in recent years. Heat
activated wire is now available that will increase
its force level as the temperature changes. These
wires exhibit a so-called shape memory effect. If
the wire is cooled and tied into the teeth it deflects
easily into position. As the wire warms in the
mouth it gradually returns to its original shape
moving the teeth with it (Figs12ac).
For optimal tooth movement it is important
that continuous gentle forces are applied to the
teeth. Fixed appliances are ideal for doing this.
When removable appliances are worn, the
patient should wear them full-time except for
cleaning and playing contact sports. Part-time
wear produces intermittent forces on the teeth
and is likely to reduce the rate of movement.
When a force is applied to a tooth, there is an
initial period of movement as the periodontal
Fig. 13 Tooth movement

requires light continuous
forces. In this graph tooth
movement in mm is shown
on the y-axis and time in
days on the x-axis. If a
force is applied to a tooth
the periodontal membrane
is compressed and there is
a small amount of initial
movement. Movement
then stops as bone cells are
recruited and the socket
starts to be remodeled.
After about 14 days
sufficient recruitment and
remodeling has occurred to
allow the tooth to move
262
Lag period
mm
1.5
1.0
0.5
0
0
8 10 12 14 16 18 20 22 24 26 28 30
Days
membrane is compressed (Fig. 13). No tooth

movement occurs for a few days after this, as
cells are recruited in order to remodel the socket
as well as the periodontal membrane. This cell
recruitment takes a few days and is known as the
lag effect. Part-time wear of appliances will not
allow efficient cell recruitment and the lag phase
will not be passed which may result in poor
tooth movement. This is another reason why
fixed appliances, which cannot be left out of the
mouth by patients, are much more effective than
removable appliances at achieving a satisfactory
treatment outcome.
RETRIEVAL AND PRESERVATION OF

ANCHORAGE
Extra-oral devices can be used for distal movement as well as anchorage reinforcement. For
anchorage control wearing the headgear at
night-time only is usually enough. In order to
produce distal movement, the patient should
wear the appliance in excess of 12 hours usually for the evenings as well as at nighttime.
While some practitioners increase the force
levels for distal movement purposes, it is our
experience that this is not necessary and a
force of approximately 250300 g per side is
adequate for both distal movement and
anchorage control.
Many devices have been described to reduce
or eliminate the need for headgear. These are
however of limited use and can only produce a
very small amount of extra space. If these gadgets are used without anchorage re-enforcement
unwanted mesial movement of the anchor teeth
could occur. Figures 14ac shows one example
known as a Jones jig. To produce distal movement of the molars the anchorage is reinforced
with an anterior trans-palatal arch. A jig incorBRITISH DENTAL JOURNAL VOLUME 196 NO. 5 MARCH 13 2004
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PRACTICE
Fig. 14a-c A Jones jig for distal movement of the molars (14a).
A palatal arch is fitted to the first premolars to increase the
anterior anchorage. A jig is then inserted into the buccal arch
wire and headgear tubes. An open nickel titanium coil spring is
then slid over the shaft of the jig and compressed by sliding a
collar onto the shaft and tying it to the premolar (14b). This
then uses the upper premolars and palatal vault to distalise
the molars (14c). Note the simultaneous mesial movement
of the first premolars which is a sign of anchorage loss
porating a nickel-titanium coil spring is inserted

into molar tubes and tied into the premolar
bands. The molars are distalised using the anterior teeth from premolar to premolar as the
anchorage block. It is important to note the loss
of anchorage that is occurring as demonstrated
by the simultaneous mesial movement of the
first premolars. Once distal movement of the
molars has been achieved the anchorage reinforcement can be transferred to the molars
(palatal arch or Nance button) and the premolars, canines and incisors retracted. True anchorage re-enforcement with these devices is difficult to achieve and headgear, or implants must
still be considered the mainstay of producing
effective distal movement.
Thanks to Mr. R Cousley for figure 6 and Mr. J Kinelan for

figures 14a-c
1.
2.
3.
4.
5.
6.
7.
Booth-Mason S, Birnie D. Penetrating eye injury from

orthodontic headgear. Eur J Orthod 1998; 10: 111-114.
Samuels R H A, M Willner F, Knox J, Jones M L. A national
survey of orthodontic face bow injuries in the UK and Eire.
Br J Orthod 1996; 23: 11-20.
Samuels R H A, Jones M L. Orthodontic face bow injuries and
safety equipment. Eur J Orthod 1994; 16: 385-394.
British Orthodontic Society, 291 Grays Inn Road, London
WC1X 8QJ.
Postlethwaite K. The range and effectiveness of safety
headgear products. Eur J Orthod I988; 11: 228-234.
Samuels R H A, Evans S M, Wigglesworth S W. Safety catch
for Kloen face bow. J Clin Orthod 1993; 27: 138-141.
Crabb J J, Wilson H J. The relation between orthodontic
spring force and space closure. Dent Pract Dent Res 1972;
22: 233-240.

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IN BRIEF
10
Check all 10-year-olds for the position of their permanent canines by initial clinical
examination and palpation, if necessary with further radiographs to locate possible
impactions
Check for late eruption of permanent incisors, if one incisor has erupted, the others should
not be far behind. If the permanent lateral incisors have erupted but not the permanent
central incisors then suspicion of impaction should be heightened
Refer too early rather than too late
VERIFIABLE
CPD PAPER
Orthodontics. Part 10: Impacted teeth

NOW AVAILABLE
AS A BDJ BOOK
This section deals with the important issue of impacted teeth. Impacted canines in Class I uncrowded cases can be improved by
removal of the deciduous canines. There is some evidence that this is true for both buccal and palatal impactions. Treatment of
impacted canines is lengthy and potentially hazardous. Interceptive measures are effective and preferred to active treatment.
Supernumerary teeth may also cause impaction of permanent incisors, their early diagnosis and appropriate treatment is
essential to optimise final outcomes. If there are any doubts about impacted teeth it is better to refer too early than too late, this
latter option may unnecessarily extend the length of treatment as well as the treatment required.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
Orthodontic
Bristol BS1 2LY;
Refereed Paper
doi:10.1038/sj.bdj.4811074
319327
This section brings together the information

general dental practitioners need in order to
diagnose and deal effectively with impacted
teeth.
IMPACTED CANINES
A canine that is prevented from erupting into a
normal position, either by bone, tooth or
fibrous tissue, can be described as impacted.
Impacted maxillary canines are seen in about
3% of the population. The majority of impacted
canines are palatal (85%), the remaining 15%
are usually buccal. There is sex bias, 70% occur
in females. One of the biggest dangers is that
they can cause resorption of the roots of the
lateral or central incisors and this is seen in
about 12% of the cases.
The cause of impaction is not known, but
these teeth develop at the orbital rims and have
a long path of eruption before they find their
way into the line of the arch. Consequently in
crowded cases there may be insufficient room
for them in the arch and they may be deflected.
It seems that the root of the lateral incisor is
important in the guidance of upper permanent
canines to their final position. There is also
some evidence that there may be genetic input
into the aetiology of the impaction.
Late referral or misdiagnosis of impacted
canines places a significant burden on the
patient in relation to how much treatment they
will subsequently need. If the canines are in poor
positions it will require a considerable amount of
treatment and effort in order to get them into the
line of the arch and a judgement must be made
as to whether it is worth it. Sacrificing the canine
is unsatisfactory since this presents a challenge
to the restorative dentist, an aesthetic problem

and by definition, cannot be used to guide the
occlusion. There are times when it might be sensible to consider its loss, but early diagnosis can
make a significant difference to how much treatment is needed by the patient.
DIAGNOSIS
It is easy to miss non-eruption of the permanent
canines, but there are some markers which
should increase suspicion of possible impaction.
Any case with a deep bite, missing lateral incisors or peg-shaped upper lateral incisors needs a
detailed examination. Figure 1 shows such a
case and in this instance both canines were significantly impacted on the palatal aspect. The
retained deciduous canine is self evident. Other
clues include root and crown positions. Figure 2
shows a lateral incisor which is proclined. There
Fig. 1 Typical features which should arouse

suspicion of impacted canines. There is a deep
bite and a small peg-shaped lateral incisor. The
retained deciduous canine is obvious. In this
patient both upper permanent canines were
palatally positioned
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Fig. 2 There are clues as to the whereabouts of the upper right

permanent canine in this patient. The upper right lateral crown
is proclined because the upper right permanent canine is
buccally positioned and therefore places pressure on the root
moving the crown of the lateral incisor labially and the root of
the lateral incisor palatally
Fig. 3 Consequences of failure to diagnose impacted canines. This

radiograph shows the roots of the upper lateral incisor to be resorbing
Fig. 4 The patient shown in Figure 3 had both lateral incisors

removed because of the severe root resorption caused by the
unerupted permanent canines
320
is a retained deciduous canine and the permanent canine lies buccal which moves the root
of the lateral incisor palatally and the crown
labially.
Any general dental examination of a patient
from the age of 10 years should include palpation for the permanent canine on the buccal
aspect. It is possible to locate the canines with
palpation, but this will lead to some false observations. For instance, the buccal root of a decidous
canine, if it is not resorbing, can feel like the
crown of the permanent tooth. It is therefore
important to back up clinical examination with
radiographs. Failure to make these observations
will eventually result in patients complaining of
loose incisors; inevitably some permanent
canines will resorb adjacent teeth with devastating efficiency as shown in Figures 3 and 4.
WHAT ARE THE BEST RADIOGRAPHIC VIEWS

TO LOCATE CANINES?
Most patients undergoing routine orthodontic
screening will have a dental pantomogram.
Location of tooth position requires two radiographs in different positions. In the interests of
radiation hygiene it is sensible to use this as
a base x-ray and to take further location radiographs in relation to the dental pantomogram.
An anterior occlusal radiograph allows this and
the principle of vertical parallax can be used to
locate the position of the canine. The tube has to
shift in order to take an anterior occlusal and it
moves in a vertical direction. If the tooth crown
appears to move in the direction of the tube shift
(ie vertically) then the tooth will be positioned
on the palatal aspect. If the crown appears to
move in the opposite direction it is buccal and if
it shows no movement at all it is in the line of
the arch (Figures 5 to 7). This also provides a reasonably detailed intra-oral view in cases of root
resorption.
Although there are other radiographic techniques which can be used to locate canines, this
method works well. If there are difficulties in
being sure of the exact location then two periapicals taken of the region with a horizontal
shift of the tube may give slightly better precision. The periapical radiographs will also give
good detail of the roots of adjacent teeth, particularly the lateral incisors. The proximity of the
canine crown to incisor roots does make them
vulnerable to root resorption. The percentage of
teeth adjacent to the crown of the canine which
undergo some form of resorption is probably
quite high at the microscopic level. No extractions should be contemplated until the canines
have been located. Figure 8 shows a dental pantomogram of a patient who had both upper and
lower first premolars removed as part of a treatment plan, but where the canines had not been
located beforehand. The dental pantomogram
clearly shows the poor position of the canines
and subsequent treatment involved the removal
of the permanent canines since their position
was deemed hopeless and movement of the
canines may well have resulted in root resorpBRITISH DENTAL JOURNAL VOLUME 196 NO. 6 MARCH 27 2004
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Fig. 5 Orthopantomograph of patient where the two canines are clearly impacted
Fig. 6 Anterior occlusal radiograph of the same

patient shown in Figure 5. Both canines are now
more apically positioned and therefore these
teeth have moved with the tube shift and are
palatally positioned
Fig. 7 Same patient as in Figures 5 and 6 with

both permanent canines exposed surgically and
on the palatal aspect
tion of the incisors. The canines had to be

replaced prosthetically and it would be difficult
to see how a legal defence of this situation could
be raised.
INTERCEPTIVE MEASURES FOR CANINES

One of the most significant publications in the
orthodontic literature came from Ericson &
Kurol (1988)1 who demonstrated that extraction of upper deciduous canines where the
upper permanent canines were developing on
the palatal aspect, resulted in nearly an 80%
chance of correcting the impaction. The paper
was very specific about what types of malocclusions this could be applied to. Nearly all the
cases were Class I with no incisor crowding.
This is important to emphasise, a subsequent
follow-up paper2 confirmed their original
observation and also indicated that the technique could not be applied easily to crowded
cases and in some cases this would result in a
worsening of the situation rather than an
improvement. The dental pantomogram of a
patient is shown in Figure 9. The canines are
palatally positioned. Since this was an
uncrowded case, the deciduous canines were
extracted and Figure 10 shows that both the
Fig. 8 Dental pantomogram of a patient who had had all four first premolars
removed without sufficient diagnostic information. The upper permanent canines are
in a very poor position and with the distinct possibility of some root resorption it was
felt that the upper permanent canines should be removed and replaced prosthetically
Fig. 9 Dental pantomogram of a patient with palatally impacted canines
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permanent canines erupted with no orthodontic assistance. Clearly this saved the patient a
considerable amount of treatment and early
appropriate referral would be wise if a general
dental practitioner is unsure. The interceptive
measure of extracting deciduous canines
works well if carried out between the ages of
1113 years. The closer the crowns are to the
mid-line the worse the prognosis. It is worth
re-emphasising that this works best in Class I
uncrowded cases.
Fig. 10 The same patient as in Figure 9. The dental pantomogram clearly shows that
both canines have disimpacted and are now erupting in the line of the arch. The only
active treatment was extraction of both upper deciduous canines
Fig. 11 Palatally impacted canines which have had a flap raised and
gold chain bonded to the crowns of the permanent canines
TREATMENT OF CANINES
The treatment of buccally or palatally impacted canines involves exposure and then a form
of traction to pull the tooth into the correct
position in the arch. Palatally impacted teeth
can be exposed and allowed to erupt. This
tends to form a better gingival attachment
since the tooth is erupting into attached
mucosa. This cuff may be lost on the palatal
aspect as the tooth is brought into line. Some
operators prefer to raise a flap, attach a bracket
pad with a gold chain to the tooth in theatre
and then replace the flap. Traction is subsequently applied to the chain and the tooth
pulled through the mucosa (Fig. 11). There is
some evidence that this procedure is less successful than a straight forward exposure. It
also has a disadvantage that if the bonded
attachment fails then a further operation,
either to expose or reattach, is needed. The
advantage with this technique is that the root
usually needs less buccal torque once the
crown is in position.
If the canine is moderately high and buccal,
it will not be possible to expose the tooth since it
will then erupt through unattached mucosa and
an apically repositioned flap should be considered. If it is very high, it is not possible to apically reposition the flap and therefore it is better in
this situation to raise a flap and bond an attachment with a gold chain. It is critical that the
chain passes underneath the attached mucosa
and exits in the space where the permanent
canine will eventually be placed as in Figure 11.
If it is not placed in this situation and exits out of
non-keratinised mucosa the final gingival
attachment will be poor (Fig. 12).
Other options include:
Accept and observe
Leaving the deciduous canine in place and either
observing the impacted canine or removing it.
Long term, the deciduous canine will need prosthetic replacement.
Fig. 12 A bucally positioned canine has had a gold chain attached

but in an incorrect position. The chain should exit mid alveolus and
from keratinised mucosa
322
Extract the impacted canine

If there is a good contact between the lateral
incisor and the first premolar then it has to be
carefully considered whether this should be
accepted. The purists of occlusion will argue that
the premolar is not capable of providing good
canine guidance. Aesthetically there are problems since the palatal cusp hangs down. This can
be disguised by grinding or rotating the tooth
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orthodontically so that the palatal cusp is positioned more distally. The placement of a veneer
on the premolar is another way of improving the
appearance.
Transplantation
Canine transplantation has received poor press
in the past. Many of the problems arose because
the canines were transplanted with a closed
apex. These teeth were seldom followed up with
root fillings on the basis that they would revascularise. This is unlikely through a closed apex
and it is preferable to treat them as if they were
non-vital. Transplantation is an option which
should only be reserved for teeth that are in
almost an impossible position and where there is
extensive hypodontia or other tooth loss.
Fig. 14 Palatally positioned canine being moved

with power chain into the correct position
Implants
Implants are also an option and as single tooth
implants improve, this may become more
favoured in future. It is important to remember
that implants in a growing child will ankylose
and appear to submerge as the alveolus continues to develop. These are not therefore an option
until the patient is at least 20 years of age.
Correction of canine position
Favourable indications for correction of
impacted canines.
Canines are moved most easily into their correct
position if the root apex is in a favourable position. If the tooth lies horizontally it is extremely
difficult to correct this and generally the closer
the tooth to the midline the more difficult the
correction will be. Treatment is nearly always
lengthy and can damage adjacent teeth. Figure
13 shows a lateral incisor adjacent to a palatally
impacted canine where the opposite reaction to
Fig. 13 A lateral incisor adjacent to a palatally

impacted canine. When the canine is pulled
labially the reaction will be for the lateral root
to move labially. It is essential therefore to use
thick rectangular wires during the movement of
palatally positioned canines. Further labial
movement of the lateral root would be
potentially damaging to the periodontal
attachment
Fig. 15 A piggy back flexible wire has been

deflected in order to apply traction to the gold
chain which has been attached to a palatally
positioned canine. There is a stiff base wire
which prevents unwanted reactions to this
traction
pulling the palatal canine out is the labial positioning of the lateral incisor root. Obviously this
is not favourable and the gingival recession will
worsen. The force to move the canines can be
obtained from elastomeric chain or thread.
Figure 14 shows elastomeric chain being used to
pull the canine labially. An attachment has been
bonded to the tooth, but as the tooth moves to its
correct position it will be necessary to rebond it.
Moving the tooth over the bite sometimes
requires the occlusion to be disengaged with a
bite plane or glass ionomer cement build ups on
posterior teeth, for a few weeks.
An alternative is to use a smaller diameter
nickel titanium piggy back wire with a stiff
base wire to align the tooth (Fig. 15). The thicker
base wire maintains the archform by resisting
local distortion caused by the traction on the
canine. The nickel titanium piggy back wire produces flexibility and a constant low force, unlike
elastomeric chain or thread which have a high
initial force and then a rapid decay of this force.
It is better not to tie the piggy back in fully as the
wire needs to be able to slide distally as the
canine moves labially. If tied in fully the friction
does not allow this function. It also helps if the
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PRACTICE
it can be seen how much tooth movement has
occurred. The transpalatal arch is also useful
anchorage for vertical and antero-posterior
tooth movements.
Fig. 16 Beta titanium sectional arch which is both

formable and flexible can be deflected to apply
traction to move the impacted canine buccally
piggy back wires run through auxiliary tubes on

the first molar bands. One further method which
has gained some popularity is the use of a sectional archwire made of beta-titanium alloy.
This wire is formable and flexible, it can be
deflected as a sectional arm and pulls the canine
labially. It is important to use a palatal arch
which cross braces the molars to prevent them
moving into crossbite as an opposite force reaction to the buccal movement of the canines
(Fig. 16).
The use of heat activated nickel titanium
alloys has also done much to improve the efficiency of moving impacted canines into the
correct position. Figures 17 and 18 show a
sequence of tooth movements where a nickel
titanium alloy has been deflected, after cooling
with a refrigerant, into the bracket. The length
of time between the two slides was 8 weeks and
Fig. 17 The impacted canine has had a heat

activated nickel titanium wire deflected into
the bracket
Fig. 18 Same patient as shown in Figure 17

nearly 8 weeks later where significant tooth
movement has taken place
324
WHAT CAN GO WRONG?

There are a number of problems with moving
permanent canines from either a buccal or a
palatal position. By and large, the older the
patient the less chance there is of succeeding,
and certainly moving canines in adults
requires caution. If the canines have to be
moved a considerable distance then ankylosis
is a distinct possibility as well as loss of vascular supply and therefore pulp death. Treatment
often takes in excess of 2 years and it is important to maintain a motivated and co-operative
patient. It is necessary to create sufficient
space for the canine to be aligned and this is
usually around 9 mm.
The periodontal condition of canines that
have been moved into the correct position in the
arch can deteriorate, this is particularly true if
care has not been taken to ensure that the canine
either erupts or is positioned into keratinised
mucosa. There may also be damage to adjacent
teeth during surgery, or indeed the surgeons can
damage the canine itself with burs or other
instruments. Figure 19 shows the crown of a
canine which has clearly been grooved by a bur
which was used for bone removal when the
canine was exposed. It is quite easy to induce
root resorption of adjacent teeth (either the lateral incisor or the first premolar), particularly if
care is not taken in the direction of traction
applied to the impacted canine. Loss of blood
supply of adjacent teeth can also occur. It is
quite common at the end of treatment to see a
slightly darker crown of the permanent canine,
this probably results from either a change in
vascularity and vitality of the canines, or potentially haemoglobin products can be produced
and seep into the dentine thus changing the
colour of the overlying enamel. The worst scenario of all is that the canine ankyloses and will
not move. The protracted length of treatment
also results in patients abandoning treatment.
Despite all of our improvements in treatment
mechanics and diagnosis for impacted canines,
the eruption path is often unpredictable.
Canines which have a seemingly hopeless prog-
Fig. 19 The crown of this canine was grooved by

a bur used during bone removal when the canine
was exposed
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PRACTICE
nosis can sometimes correct their position and
erupt. Nevertheless, to sit and observe a patient
where the canines are clearly in difficulty without referral to a specialist would be difficult to
defend legally. Hopefully the days of patients
arriving in orthodontic departments with
retained deciduous teeth at the age of 16 will
diminish as the profession takes on the challenge of life long learning.
OTHER IMPACTED TEETH

The most common cause of unerupted maxillary
incisors is the presence of a supernumerary
tooth. These are often typed as follows:
Conical
Tuberculate
Odontomes (complex or compound)
Supplemental teeth
There are some conditions which have a

genetic basis where impacted teeth are seen
more frequently and this includes cleidocranial
dysplasia, cleft lip and palate, gingival fibromatosis and Down's Syndrome.
It is worth remembering that most central
incisors should have erupted by the age of 7 and
lateral incisors by the age of 8. Surprisingly, most
referrals for impacted maxillary incisors are
when the patient is 9 years of age. This delay in
diagnosis could potentially influence the outcome and it is important that when the contralateral incisor has erupted 6 months previously
there is likely to be a problem. Similarly, if the
lateral incisors erupt well before the central incisor then consideration should be given to investigating further (Fig. 20).
It is perfectly possible that a supernumerary
tooth may be present and not affect the eruption of the incisors (Fig. 21). Indeed one of the
clinical signs that a supernumerary may be
present is the evidence of spacing where
a supernumerary is in the midline and causing
a diastema between the upper incisors. The different types of supernumerary teeth seem to
have different implications for treatment.
Conical supernumerary teeth are small and
peg-shaped, they usually have a root and they
do not often affect incisor eruption (Fig. 21), but
if they are in the midline they can cause a median diastema. They should only be removed if
they are adjacent to incisors which need to
undergo root movement. Potentially the movement of the root against the supernumerary
tooth could cause resorption of an incisor root.
Where the supernumerary teeth are tuberculate these usually have no roots and develop
palatally. They often prevent the eruption of
central incisors and if they do, they need to be
removed (Fig. 22). Complex and compound
odontomes are rare, but can similarly prevent
eruption of the permanent incisors and also
need to be removed. Obviously, radiographs are
needed to confirm any clinical observations
about impacted teeth and parallax used in the
same way as for canines in order to locate the
position of the supernumerary teeth. Eighty per
Fig. 20 This patient has both her lateral incisors fairly well erupted
but retained deciduous teeth. This could easily have been diagnosed
sooner and may influence the outcome of final tooth position
Fig. 21 Conical supernumerary which has

not inhibited the eruption of the
permanent incisors. The supernumerary
is in the midline
Fig. 22 Anterior occlusal radiograph which shows both upper

lateral incisors to have erupted, both upper deciduous central
incisors are retained and the upper permanent central incisors are
unerupted. There are two tuberculate supernumeraries present
which are associated with the non-eruption of these upper
permanent central incisors
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cent of supernumerary teeth occur in the anterior part of the maxilla and there is a male to
female ratio of 2:1. The incidence in the population as a whole varies, but is somewhere in the
region of 12%.
Fig. 23 Typical fibrous tissue impaction of the permanent incisor. In this patient a
supernumerary had been removed 9 months earlier. The tooth will only require a
small exposure on the palatal aspect to enable it to erupt. The bulge in the labial
mucosa is clearly evident and this is where the crown will sit
Fig. 24 Dental pantomogram of a patient who appears to have

severe impaction of her lower left second premolar
Fig. 25 The same patient as in Figure 24, 9 months later where

there has been good eruption of the lower left second premolar.
Eventually this tooth made its way fully into the line of the arch
and it was possible to upright the lower left first molar
326
Treatment of impacted supernumeraries

Although guidelines have been published from
the Royal College of Surgeons,3 these review
what the options are rather than defining what
the best treatment is. In part this is due to a
lack of good research to show what the best
methods are.
Obviously if there is an obstruction the sooner
it is removed the better. Some suggest exposing
the incisor at the same time or attachment of a
gold chain in order to prevent re-operation if the
tooth fails to erupt. However, this is potentially
damaging, particularly if bone has to be
removed in order to expose or bond an attachment to the tooth with a gold chain brought out
through the mucosa in order to place traction
and move the impacted incisor.
If diagnosed early and the supernumerary is
removed when the apex of the incisor is open
then eruption of the tooth can be anticipated.
Even if there is a need to re-operate at a later
date, if the tooth has come further down it is
much easier to either expose the tooth or raise a
flap and place an attachment on an incisal edge
that is now much closer to its correct position.
Often incisors will erupt quite a long way and
then become impacted in fibrous tissue (Fig. 23).
In this situation it only requires a small exposure
usually on the palatal aspect to allow the tooth
to come down. Apically repositioned flaps are
often disastrous and produce poor mucosal
attachment. In the main they should be avoided.
Fixed appliances are usually needed in order
to regain lost space where adjacent teeth have
drifted and these appliances are also useful if
traction does need to be applied to the impacted
teeth. Removable appliances in this situation are
often cumbersome, although they have been
used with a magnet bonded to the unerupted
tooth and a further magnet embedded into the
removable appliance in order to bring the tooth
down. The use of fixed appliances in this situation allows alignment, space management and
overbite correction. Ultimately the early diagnosis of unerupted teeth is the biggest contribution
a practitioner can make to the management of
impacted teeth.
IMPACTED PREMOLARS
Where crowding exists or where there has been
early loss of deciduous molars, premolars are
sometimes unable to erupt. Often relief of
crowding (usually extraction of first premolars)
allows impacted second premolars to erupt. Second premolars do seem to have enormous potential to erupt and given time these teeth often find
their way into the arch (Figs 24 and 25). Often in
the upper arch they displace palatally. There may
also be clues from the deciduous teeth. If the
deciduous teeth become ankylosed they often
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appear to submerge as alveolar bone growth
continues. This may indicate the absence of a
second premolar, but sometimes this submergence can be seen when permanent successors
are present. Most of these situations will resolve,
but it is thought wise to consider removing the
second deciduous molar if it slips below the contact points and there is then space loss as the
molar tips forward. Where first molar mesial
migration compromises the contact point relationship, space maintenance might be considered. Figure 26 shows a radiograph of a patient
who appears to have generalised submergence
since all second deciduous molars are seen to be
submerging in all four quadrants. In this situation continued observation of the development
of the occlusion with appropriate loss of deciduous molars is essential. With the extensive
restorations and caries, an argument could be
made for loss of all four first molars in this case.
OTHER IMPACTIONS
The only other impactions to be considered in a
general form are first molars. These may impact
in soft tissue and it is sometimes worth considering occlusal exposure where a first molar has not
erupted. This usually occurs in the upper arch
and can be accepted if the oral hygiene is good
with minimal caries experience. Impacted molars
of this type quite frequently self correct before or
during eruption of the second premolar. There
may also be primary failure of eruption and if the
tooth fails to move with orthodontic traction this
is usually a good indication that the tooth will
not move. First molars may also impact into second deciduous molars as they erupt and the
options then are to try and move the molar distally with a headgear or removable appliance, to
consider using separators (brass wire) to relieve
Fig. 26 Dental pantomogram of a patient with all four second

deciduous molars submerging. Those which are below the contact
point (upper right second deciduous molar) should probably be
removed in order to aid eruption. The others should be observed
the impaction or ultimately to remove the second

deciduous molar if any of these methods fail to
relieve the impaction.
It is clear that the biggest single contribution
that can be made to the treatment of impacted
teeth is to improve diagnostic skills and define
care pathways with clinical protocols. Early
referral does not harm, a late referral will
increase the burden of care for patients and
practitioners.
1.
2.
3.
Ericson S, Kurol J. Early treatment of palatally erupting

maxillary canines by extraction of the primary canine. Eur J
Orthod 1988; 10: 283-295.
Power S, Short M B E. An investigation into the response of
palatally displaced canines to the removal of deciduous
canines and an assessment of factors contributing to
favourable eruption. Br J Orthod 1993; 20: 215-223.
National Clinical Guidelines. Faculty of Dental Surgery, Royal
College of Surgeons of England, 1997.

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327
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PRACTICE
IN BRIEF
The osteoblast is the pivotal cell in bone remodelling and the link between the osteoblast and
osteoclast recruitment and activation is now established
Excessive orthodontic forces cause inefficient tooth movement and adverse tissue reactions
The mechanisms which prevent root resorption are not fully understood but it remains a
consequence of any orthodontic treatment. The extent and degree of root resorption cannot
be predicted but some indicators are available
11
Orthodontics. Part 11: Orthodontic tooth movement

NOW AVAILABLE
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VERIFIABLE
CPD PAPER
Orthodontic tooth movement is dependent on efficient remodelling of bone. The cell-cell interactions are now more fully understood
and the links between osteoblasts and osteoclasts appear to be governed by the production and responses of osteoprotegerin ligand.
The theories of orthodontic tooth movement remain speculative but the histological documentation is unequivocal.
A periodontal ligament placed under pressure will result in bone resorption whereas a periodontal ligament under tension results in
bone formation. This phenomenon may be applicable to the generation of new bone in relation to limb lengthening and cranialsuture distraction. It must be remembered that orthodontic tooth movement will result in root resorption at the microscopic level in
every case. Usually this repairs but some root characteristics apparent on radiographs before treatment begins may be indicative of
likely root resorption. Some orthodontic procedures (such as fixed appliances) are also known to cause root resorption.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
Orthodontic
Bristol BS1 2LY;
Refereed Paper
doi:10.1038/sj.bdj.4811129
391394
The histological changes which occur when

forces are applied to teeth are well documented
(Figs 1 and 2). Teeth appear to lie in a position of
balance between the tongue and lips or cheeks.
This zone is not completely neutral since tongue
forces are usually slightly greater than the lips or
cheeks. The periodontal ligament is thought to
have an intrinsic force which has to be overcome
before teeth move. A notable feature of periodontal disease, where this intrinsic force is lost,
is splaying, drifting and spacing of teeth. Similarly, if there is excessive tongue activity or
destruction of the lips or cheeks (as in cancrum
oris) then the teeth will drift.
Very low forces are capable of moving teeth.
Classically, ideal forces in orthodontic tooth
movement are those which just overcome capillary blood pressure. In this situation bone
resorption is seen on the pressure side and bone
deposition on the tension side. Teeth rarely
move in this ideal way. Usually force is not
applied evenly and teeth move by a series of tipping and uprighting movements. In some areas
excessive pressure results in hyalanization
where the cellular component of the periodontal
ligament disappears. The hyalanized zone
assumes a ground glass appearance but this
returns to normal once the pressure is reduced
and the periodontal ligament repopulated with
normal cells. In this situation a different type of
resorption is seen whereby osteoclasts appear to
undermine bone rather than resorbing at the
frontal edge (Fig. 3).
Mechanically induced remodelling is not
fully understood. The role of the periodontal
ligament has been questioned since tooth
movement can still occur even where the peri-
BRITISH DENTAL JOURNAL VOLUME 196 NO. 7 APRIL 10 2004
odontal ligament is not functioning normally.

The ligament itself undergoes remodelling and
the role of matrix metalloproteinases (MMPs)
together with their natural inhibitors, tissue
inhibitors of metalloproteinases (TIMPs) are
clearly of importance.1
Osteocytes (osteoblasts incorporated into
mineralized bone matrix) are situated in a rigid
matrix and are thus ideally positioned to detect
changes in mechanical stresses. They could
signal to surface lining osteoblasts and thus
bone formation and indeed bone resorption
may result. There is now good understanding of
key mechanisms in bone resorption and formation. Bone is formed by osteoblasts which also
have a role in bone resorption. It is the
osteoblast which has receptors for many of the
hormones and growth factors which stimulate
bone turnover.
By contrast, the osteoclast which resorbs
mineralised tissue, responds to very few direct
hormone actions. Most of the classic agents
which have direct effects on osteoclasts have
inhibitory actions. For example, Calcitonin and
prostaglandin E2 will inhibit osteoclasts from
resorbing calcified matrices.
The recruitment and activation of osteoclasts to sites of resorption comes from the
osteoblast when the latter cell is stimulated
by various hormones. The signal link from
osteoblasts has recently been identified as
osteoprotegerin (OPG) and the ligand (OPGL).
They both potently inhibit and stimulate
respectively, osteoclast differentiation. Furthermore, OPGL appears to have direct effects
on stimulating mature osteoclasts into activity. If OPGL is injected into mice there is an
391
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PRACTICE
Fig. 1 Pressure side of a tooth being moved. The very vascular

periodontal ligament has cementum on one side and bone on the
other where frontal resorption is occurring. Osteoclasts can be seen
in their lacunae resorbing bone on it's frontal edge
Intermittent forces
appear to move teeth
and stimulate bone
remodelling more
efficiently than
continuous forces
392
Fig. 2 This is a tension site where the bone adjacent to the

periodontal ligament has surface lining osteoblasts and no sign of
any osteoclasts. New bone is laid down as the tooth moves
increase in ionised blood calcium within

1 hour. These finding have done much to
unravel the final links between bone formation and resorption.
One other role that osteoblasts have in bone
resorption is removal of the non-mineralised
osteoid layer. In response to bone resorbing hormones, the osteoblast secretes MMPs which are
responsible for removal of osteoid. This exposes
the mineral layer to osteoclasts for resorption. It
has been suggested that the mineral is also
chemotactic for osteoclast recruitment and
function.
How mechanical forces stimulate bone
remodelling remains a mystery but some key
facts are known. First, intermittent forces
stimulate more bone remodelling than continuous forces. It is likely that during orthodontic
tooth movement intermittent forces are generated because of jiggling effects as teeth come
into occlusal contact. Second, the key regulatory cell in bone metabolism is the osteoblast.
It is therefore relevant to examine what effects
mechanical forces have on these cells. The
application of a force to a cell membrane triggers off a number of responses inside the cell
and this is usually mediated by second messengers. It is known that cyclic AMP, inositol
phosphates and intracellular calcium are all
elevated by mechanical forces. Indeed the
entry of calcium to the cell may come from
G-protein controlled ion channels or release
of calcium from internal cellular stores. These
messengers will evoke a nuclear response
which will either result in production of factors responsible for osteoclast recruitment and
activation, or bone forming growth factors.
An indirect pathway of activation also exists
whereby membrane enzymes (phospholipase
A2) make substrate (arachidonic acid) available for the generation of prostaglandins and
leukotrienes. These compounds have both
been implicated in tooth movement.
The main theories of tooth movement are
now summarised:
BIOMECHANCIAL ORTHODONTIC TOOTH

MOVEMENT
This theory simply states that mechanically distorting a cell membrane activates PLA2 making
arachidonic acid available for the action of cyclo
and lipoxygenase enzymes. This produces
prostaglandins which feed back onto the cell
membrane binding to receptors which then
stimulate second messengers and elicit a cell
response. Ultimately, these responses will
include bone being laid down in tension sites
and bone being resorbed at pressure sites. It is
not clear how tissues discriminate between tension and pressure. It is worth remembering that
cells which are rounded up show catabolic
changes whereas flattened cells (? under tension)
have anabolic effects.
BONE BENDING, PIEZOELECTRIC AND
MAGNETIC FORCES
There was considerable interest in piezoelectricity
as a stimulus for bone remodelling during the
1960s. This arose because it was noted that distortion of crystalline structures generated small electrical charges, which potentially may have been
responsible for signalling bone changes associated with mechanical forces. The interest therefore
in electricity and bone was considerable.
Magnets have been used to provide the force
needed for orthodontic tooth movement. Classically an unerupted tooth has a magnet attached
to it and a second magnet is placed on an orthodontic appliance with the poles orientated to
provide an attractive force. It is unlikely that the
magnetic forces alone have any actions on tissues. If magnetic fields are broken (as in pulsed
electromagnetic fields) then there is some evidence that tissues will respond. It is worth making the following points about the effects of
magnetic and electric fields on tooth movement:
The periodontal ligament is unlikely to transfer forces to bone. If the periodontal ligament
is disrupted, orthodontic tooth movement still
occurs
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PRACTICE
Magnetic fields alone have little, if any, effect
on tissues
Pulsed magnetic fields (which induce electric
fields) can increase the rate and amount of
tooth movement
When an orthodontic force is applied, the
tooth is displaced many times more than the
periodontal ligament width. Bone bending
must therefore occur in order to account for
the tooth movement over and above the width
of the periodontal ligament
Physically distorting dry bone produces
piezoelectric forces which have been implicated in tooth movement. Piezoelectric forces are
those charges which develop as a consequence
of distorting any crystalline structure. The
magnitude of the charges is very small and
there is some doubt whether they are sufficient to induce cellular change.
It must also be remembered that in hydrated
tissues, streaming potential and nerve impulses produce larger electrical fields and thus it is
unlikely that piezoelectric forces alone are
responsible for tooth movement.2
A wider application of the phenomenon of
mechanically induced bone remodelling is
seen where sutures are stretched. In young
orthodontic patients the midline palatal
suture can be split using rapid maxillary
expansion techniques. The resulting tension
generates new bone which fills in between the
distracted maxillary shelves. A similar technique is also used to lengthen limbs. This
Fig. 3 This is an area of excessive pressure

where the periodontal ligament has been
crushed or hylanized and the periodontal
ligament has lost its structure. There is a large
cell lying in a lacunae behind the frontal edge
which is probably an area of undermining
resorption
method, known as distraction osteogenesis,

can be used in any situation where it is hoped
that new bone will be generated. Originally
this was described in Russia where many soldiers returning from war faced the problem of
non-union limb fractures. Initially attempts
were made to induce new bone formation by
compressing bone ends. It was only when a
patient inadvertently turned the screw for
compression of bone ends in the wrong direction that it was noted excessive new bone formation was seen where bone ends were distracted rather than compressed.
This may also have application in patients
whose sutures fuse prematurely (craniosynostoses such as Crouzon's or Aperts Syndrome).
In this situation continued growth of the brain
results in a characteristic appearance of the
cranium but more importantly the eyes
become protuberant with possible damage to
the optic nerve. Treatment involves surgically
opening the prematurely fused sutures and
burring out to enable normal brain growth. If
distraction forces are applied prior to this early
fusion then bony infill could occur at a controlled rate. The phenomenon of pressure
resulting in bone loss is also seen in pathological lesions. Much work was done to examine
pressures within cystic lesions and to equate
this with the rate of bone destruction. It is now
recognised that cytokines and bone resorbing
factors produced by cystic and malignant
lesions are more likely to be responsible for the
associated bone resorption.
Tension results in
bone formation, this
can be used to
generate new bone
for digit lengthening
or suture distraction
Fig. 4 Area of root resorption associated with

orthodontic tooth movement. The apex of
the tooth has a large excavation of the root
surface and this is typical of excessive
tipping forces that are placed on the apices
of the teeth
393
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PRACTICE
ROOT RESORPTION
The ability to move teeth through bone is
dependent on bone being resorbed and tooth
roots remaining intact. It is highly probable that
all teeth which have undergone orthodontic
tooth movement exhibit some degree of microscopic root resorption (Fig. 4). Excessive root
resorption is found in 35% of orthodontic
patients. Some teeth are more susceptible than
others, upper lateral incisors can, on average,
lose 2 mm of root length during a course of fixed
orthodontic treatment. There are specific features of appliances which can increase the risk of
root resorption. The following are considered
risk factors:
Fixed appliances
Class II elastics
Rectangular wires
Orthognathic surgery
There is also some evidence that the use of

functional appliances appears to cause less
resorption than fixed appliances and may be
used to reduce increased overjet where there are
recognised risks of root resorption which include
pre-existing features such as:
Cementum has anti-angiogenic properties.

This means blood vessels are inhibited from
forming adjacent to cementum and osteoclasts have less access for resorption.
Periodontal ligament fibres are inserted more
densely in cementum than alveolar bone and
thus osteoclasts have less access to the cemental layer.
Cementum is harder than bone and more
densely mineralised.
Cemental repair may be by a material which is
intermediate between bone and cementum.
These semi-bone like cells may be more
responsive to systemic factors such as parathyroid hormone and thus where roots are already
short (and repaired with a bone/cementum like
material) the teeth are more susceptible to further root resorption.
The exact reason why roots generally do not
resorb is not known but without this property it
would not be possible to move teeth orthodontically. A number of reviews are available which
cover bone remodelling and tooth movement in
greater depth.3,4
1.
Short roots
Blunt root apices
Thin conical roots
Root filled teeth
Teeth which have been previously traumatised
Waddington R J, Embery G, Samuels R H. Characterization of

proteoglycan metabolites in human gingival fluid during
orthodontic tooth movement. Arch Oral Biol 1994; 39: 361368.
McDonald F. Electrical effects at the bone surface. Eur J
Orthod 1993; 15: 175-183.
Hill P A. Bone remodelling. Br J Orthod 1998; 25: 101-107.
Sandy J R, Farndale R W, Meikle M C. Recent advances in
understanding mechanically-induced bone remodelling and
their relevance to orthodontic theory and practice. Am J
Orthod Dento-fac Orthop 1993; 103: 212-222.
2.
3.
4.
What prevents roots from resorbing is not

known but the following have been suggested:
Shirley Glasstone Hughes Memorial Prize for Dental Research

The British Dental Association Research Foundation
invites applications for awards from the Shirley Glasstone
Hughes Memorial Prize Fund.
The Prize may be awarded as a single three year project
grant commencing in 2004, to a maximum of 16,000
including all salary on costs' and running expenses.
Alternatively, smaller grants may be made to more
projects, to the same total. Applications will be
considered from dentists in all fields of practice.
Where applications are made by dentists who are not
in university employment, the Foundation advises that
applications should include appropriate supervisory
arrangements involving an independent experienced
researcher.
The Foundation will favour projects, which will yield
results of direct clinical relevance.
394
Application forms
and further
information are
available from:
BDA Awards Officer,
Members Services
Department
British Dental
Association,
64 Wimpole Street,
London W1G 8YS
Tel: 020 7563 4174
Email: awards@bda.org
The closing date for applications is Friday 30th April 2004.
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PRACTICE
IN BRIEF
The dental specialities can collaborate with the treatment of complex cases
Joint treatment planning is essential
A clear treatment plan must be agreed by all parties prior to treatment starting
Responsibility for each treatment stage must be agreed in advance
Combined treatment can produce high quality treatment outcomes in complex cases
12
NOW AVAILABLE
AS A BDJ BOOK
VERIFIABLE
CPD PAPER
Orthodontics. Part 12: Combined orthodontic

treatment
Dentistry is becoming more sophisticated and capable of providing much higher treatment standards than ever before.
Treatments previously considered impossible can now be achieved as a direct consequence of these advances. However, this
increased complexity of treatment also means that the different branches of dentistry have, as a necessity, become more and
more specialised. It is important that the specialities collaborate in a systematic focused way to ensure the optimal treatment
outcome with the minimum burden of care for the patient.
ORTHODONTICS
1. Who needs
orthodontics?
examination I
examination II
treatment
orthodontics
8. Extractions in
orthodontics
distal movement
10. Impacted teeth
movement
treatment
Recent advances in dentistry, coupled with

patients increased expectations and demands,
means that some areas of clinical practice have
become more specialised. An individual dentist
is unlikely to have the necessary skills and
expertise to undertake all aspects of treatment.
In the management of complex cases joint planning between the orthodontist and the other
dental specialities is important if a satisfactory
treatment outcome is to be obtained. The dental
specialities cannot work in isolation, and jointworking relationships should be fostered. Whilst
orthodontists may be highly skilled in moving
teeth, they are heavily dependent on other dental
disciplines if optimal treatment outcomes are to
be achieved in complex cases.
There are many areas in which orthodontic
treatment may be of help to other dental specialities. Some of these are as follows:
Missing teeth
Traumatised teeth
Periodontal problems
Occlusal problems
Surgical problems

Refereed Paper
doi:10.1038/sj.bdj.4811174
449455
MISSING TEETH
The choice in these cases is usually to recreate
space for the prosthetic replacement of missing
teeth, or to close the space instead.
If an upper central incisor is missing then the
usual choice is to open up the space and put in
some form of prosthesis. If the space is closed
and the lateral incisor is placed in the central
incisor site, then camouflage is difficult because
of the small width of the lateral that results in an

unsightly emergence angle of the crown. In
cases where an upper incisor is missing, the
space may need to be re-distributed. The patient
in Figure 1 had a partial upper denture, and it
was difficult to restore the site with a bridge
because of the inclination of the upper lateral
incisor and the generalised spacing in the upper
labial segment. Fixed appliances were therefore
used to re-distribute the space in the upper arch.
In order to maintain the appearance, a bracket
was fitted to a denture tooth. At the completion
of treatment the patient was fitted with an upper
removable retainer carrying a denture tooth.
Note the proximal metal stops on the upper right
central and upper left lateral incisor, to prevent
a space re-opening during retention. Finally
a bonded bridge restored the site.
When lateral incisors are missing the choice is
not so clear-cut, and often depends on the
amount of spacing the patient has, the buccal
occlusion and the shape and colour of the
canines. Opening the space for prosthetic
replacement produces optimal aesthetics but has
the disadvantage of the maintenance involved
with this type of restorative treatment. Closing
the space obviates the need for false teeth but
this may produce a less satisfactory appearance.
Where there is considerable space, the buccal occlusion is well inter-cuspated and the
canine has a pointed cusp tip then the usual
treatment is to open the spaces. Closing spaces
will affect the buccal occlusion, and if it is a
well interdigitated Class I then this may not be
the best option. The shape of the canines is
449
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PRACTICE
Fig.1a,b A patient with a missing upper left central incisor,

which has been replaced with an inadequate denture
Fig. 1c A fixed appliance with a denture tooth to mask the space
Fig. 1e A retainer with a denture tooth. Note the proximal

metal stops. If these are not used there is a risk of the teeth
sliding past the denture tooth.
Fig. 1d The space has been redistributed
Fig. 1f A bonded bridge was placed 1 year after the removal of

the fixed appliance
important because if they are pointed they will

look unsightly adjacent to the central incisor.
Although the tips of the teeth can be trimmed
to improve their appearance, this is not always
the best choice. Figure 2 shows a case with
spacing in the upper arch due to developmentally absent upper lateral incisors. The upper
canines have very pointed tips and it would be
difficult to modify the shape of these teeth to
make them resemble lateral incisors. In addition, the buccal occlusion would make space
closure very difficult. Therefore, space in the
upper arch was recreated to allow prosthetic
replacement. An upper fixed appliance with
coil springs at the upper lateral incisor sites
accomplished this task. At the completion of
treatment, an upper retainer with denture teeth
450
was used to restore the missing sites. This

retainer was worn for a year prior to definitive
restoration with adhesive bridgework.
If the canine teeth are more amenable to
masking, and the buccal occlusion is not well
inter-cuspated with less spacing in the upper
arch, then consideration can be given to space
closure. Figure 3 shows a case where this was
accomplished, again using a fixed appliance and
the tips of the canines subsequently trimmed. A
good aesthetic appearance was achieved, but it
is worth noting the slightly different colour of
the canines in relation to the central incisors. If
necessary, this can then be masked with veneers.
Before the decision to open or close spaces is
made, consultation with a restorative dentist or
the patient's GDP is a pre-requisite.
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PRACTICE
Fig. 2a A patient with missing upper lateral incisors and

spacing
Fig. 2c Following removal of the fixed appliance
TRAUMATISED TEETH
Traumatised, fractured, intruded or avulsed
teeth may sometimes benefit from an orthodontic input. Teeth, which are fractured or intruded,
may need extrusion, and this can be accomplished by using a number of different appliances and techniques. Figure 4 is an example of
an upper appliance being used to extrude two
unerupted upper incisors as an interceptive form
of treatment. The upper permanent lateral incisors had already erupted; a clear sign that something was wrong. A supernumerary tooth, preventing the eruption of the central incisors, was
first removed and brackets bonded to the central
incisors. A modified palatal arch was then fitted
and attached to the central incisor brackets with
wire ligatures. The ligatures were gently activated
to extrude the teeth. Once the teeth had erupted
the remaining dentition was then allowed to
develop prior to definitive orthodontic treatment. A similar technique can also be used to
extrude fractured roots so that post-crowns can
be placed on the teeth.
If upper incisors are traumatised and have a
poor prognosis it is occasionally possible to
transplant teeth to restore these sites. The main
principles of transplantation have been well
documented by Andreasen1 and provided these
are followed, success rates in excess of 90% can
be expected. Premolars are good teeth to replace
upper central incisors because they often have
the same width at the gingival margin as the
teeth they are replacing. Figure 5 shows an
Fig.2b A fixed appliance with coil springs to re-open the

spaces for the lateral incisors
Fig. 2d A retainer with denture teeth was fitted and worn for
one year prior to definitive restorative treatment
Fig. 3a Another case with missing upper lateral incisors
Fig. 3b Because the spaces were small these were closed up using a
fixed appliance
451
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PRACTICE
example of a case where the upper incisors had a
poor prognosis and were extracted. The lower
first premolars were then transplanted into the
extraction sites. Veneers were then placed on the
premolars to produce a satisfactory treatment
outcome. The advantage of transplantation over
implants is that transplantation can be undertaken at an early age and will grow as the patient
grows. If an implant were placed at this stage it
would, as the child grows, become gradually
submerged. There is also a risk of ridge resorption by waiting until the patient is old enough to
have an implant placed. In addition the cost of
transplantation is also considerably less than for
implants.
PERIODONTAL PROBLEMS
With advanced periodontal disease, teeth are
prone to drift producing an unsightly appearance. The teeth can be realigned orthodontically,
but prior to this it is essential that all pre-existing periodontal disease is eliminated and the
patient can maintain a meticulous standard of
oral hygiene. If treatment is undertaken in the
Fig. 4a The
presence of a
supernumerary
tooth prevented
the eruption of the
upper central
incisors
Fig. 4b The
supernumerary was
surgically removed
and brackets bonded
to the upper
incisors. A modified
trans-palatal bar
with wire ligatures
was used to extrude
the teeth
Fig. 4c Once the

teeth were
successfully
extruded the
dentition was
allowed to develop
prior to
comprehensive
treatment in the
permanent
dentition
452
presence of active disease, very rapid bone loss

can result.
Figure 6 shows a patient who had substantial
vertical and horizontal bone loss, and as a consequence, drifting of the upper teeth had
occurred, in particular the upper lateral incisor.
Alignment of the teeth was achieved using fixed
appliances. Near the completion of treatment a
residual black triangle was left between the
upper incisors. This is quite a common problem
in adults and is caused by the inability of the
gingival tissue to regenerate and re-form an
inter-dental papilla. In order to reduce the size of
the black triangle, some inter-proximal reduction was undertaken to reshape the mesial contact points of the incisors allowing the teeth to
be brought more closely together. Permanent
retention is needed in situations like this because
the tooth will drift as soon as the appliances are
removed.
OCCLUSAL PROBLEMS
Orthodontics can be used to try and produce an
optimal occlusion, and there are many situations in which this can be used.2 The occlusion
can be adjusted to provide canine guidance,
and eliminate non-working side interferences.
In situations where anterior open bites exist, it
is occasionally possible to close these down
without the need to resort to surgery.3
Sometimes the occlusion can damage the
teeth and supporting tissues. Figure 8 is an
example of a patient with a unilateral cross bite
extending from the upper central incisor to the
terminal molar on the right hand side. This
traumatic occlusion had produced substantial
tooth wear. Treatment was carried out using an
upper fixed appliance in conjunction with a
quad helix to expand the upper arch, correct
the cross-bite and align the teeth. At the completion of treatment the incisal tips were
restored with composite.
SURGERY
There is a limit to how much tooth movement
can be achieved, and in cases with severe skeletal discrepancies, orthodontics alone is not
capable of correcting the incisor relationship,
or improving facial aesthetics. In these circumstances close liaison with an oral and maxillofacial surgeon will be required. An outline of
the processes involved and the orthodontists
role in orthognathic surgery has recently been
reviewed.4
Figure 7 shows an example of a patient with a
Class III skeletal pattern. There has been some
dento-alveolar compensation with the lower
incisors retroclined and the upper incisors proclined in an attempt to make incisal contact.
There is no scope for correcting the incisor relationship further with orthodontics alone. A combined orthodontic/surgical protocol was established and the patient started treatment with
fixed appliances, in order to decompensate the
incisors. This made the incisor relationship and
the facial profile worse. Clearly, patients need to
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PRACTICE
Fig. 5a Both the upper central incisors had been badly

damaged after a fall
Fig. 5b A peri-apical
radiograph indicated
that the teeth had a
hopeless prognosis
Fig. 5c The teeth were extracted and two lower premolars

transplanted into the extraction sites. The teeth were then
aligned with fixed appliances
Fig. 5d At the completion of fixed appliance treatment

veneers were placed on the transplanted teeth
Fig. 6a The patient complained that her teeth had moved and
were getting worse. She had extensive periodontal disease
that needed addressing prior to any orthodontic treatment
Fig. 6b Fixed appliances were then used to realign the teeth
Fig. 6c A dark triangle between the anterior teeth is a

common complication of treatment in adults. This is because
the inter-dental papilla fails to regenerate
Fig. 6d Inter-proximal reduction (slenderizarition) of the

contact points helped to substantially reduce the gap and
improve the aesthetics
453
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PRACTICE
Fig. 7a-d Pre-treatment

photographs of a patient with a
Class III incisor relationship and
skeletal pattern. The problem is
beyond the scope of
orthodontics alone because of
the skeletal discrepancy
Fig. 7e Fixed appliances were used to decompensate the

incisors and co-ordinate the arches prior to bi-maxillary
orthognathic surgery
Fig. 7f-i The completed case
454
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PRACTICE
Fig. 8a,b A right-sided cross bite has produced substantial

occlusal wear. This would be impossible to correct
restoratively with this occlusion
Fig. 8c An upper fixed appliance with a quad helix was used

to expand the upper arch, correct the incisor relationship and
align the teeth
be advised of this prior to the commencement of

treatment. Once the incisors are decompensated
and the arches co-ordinated the patient is ready
for surgery. The maxilla was advanced 7 mm
and the mandible set back by 6 mm, producing
an overall change of 13 mm in the skeletal relationship. In addition, because the patient had a
facial asymmetry, the mandible was rotated in
order to correct this.
As dentistry becomes increasingly sophisticated with more treatment options available
than ever before, no single specialty in dentistry
can work alone to provide the full range of treatment options. Some of the most interesting
aspects of orthodontic treatment come from
Fig. 8d At the completion of orthodontic treatment

the teeth were restored with composite
working in a combined approach with ones colleagues and it is important to recognize and
respect the skills of other disciplines. Work of
this nature can be amongst the most satisfying
both for the clinician and the patient.
The authors thank Paul Cook for the use of figures 5(a-d)
1.
2.
3.
4.
Andreasen J O, Andreasen F. Textbook and color atlas of

traumatic injuries to the teeth. 3rd ed. pp671-690.
Munksgaard, Copenhagen: Mosby, 1994.
Davies S J, Gray R M J, Sandler P J, O'Brien K D O.
Orthodontics and occlusion. Br Dent J 2001; 191: 539-549.
Kim Y H. Anterior openbite and its treatment with multiloop
edgewise archwire. Angle Orthod 1987; 57: 290-321.
Sandy J R, Irvine G H, Leach A. Update on orthognathic
surgery. Dent Update 2001; 28: 337-345.
Guest Leaders
Guest leaders in the BDJ are there to provide an opportunity for anyone involved in
dentistry (including patients) to write an appropriate comment for publication. These
are published to accompany the usual Leader from the Editor
Submissions must be between 200 and 500 words, typed and double-spaced.
Name, address and telephone number should be supplied, as well as your position in
the dental world.
For further help and guidance, please contact:
The Editor, British Dental Journal, 64 Wimpole Street, London W1G 8YS or
E-mail: k.maynard@bda.org
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A Clinical Guide To Othodontics

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A Clinical Guide To Othodontics

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PRACTICE

This series of articles is designed to aid in the orthodontic evaluation of patients

Orthodontics. Part 1: Who needs orthodontics?

Orthodontics comes from the Greek words

Department, Leeds Dental Institute,

Fig. 1a A child with a Class II

1*Consultant Orthodontist, Orthodontic

Fig. 1b The same child as

Fig. 2a Same child as in

Table 1 Features children most dislike or are teased

Fig. 3 This patient

Fig. 2b Occlusion of the same

3. To eliminate occlusion that could damage the

DENTO FACIAL APPEARANCE

Table 2 Relation between size of overjet and

Certain other occlusal relationships are also

Fig. 5a Anterior crossbite in a 60-year-old man occluding

Fig. 5b Shows the retruded contact position of the patient.

Fig. 5c The patient in fixed appliances in order to

Fig. 5d After correction and space reorganisation the patient

BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 2003

Fig. 7 The same

Table 3 Index of Treatment Need

spontaneously and no long-term problems usually develop.

WHO SHOULD BE TREATED?

Fig. 8a This malocclusion has an extremely deep bite which

Fig. 8b The same patient as in Fig. 8a, but not in

BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 2003

Fig. 9 The Index of

Shaw W C, Meek S C, Jones D S. Nicknames, teasing,

BDA Information Centre Services

BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 2003

There is a small charge for this service

Careful patient assessment is the most important part of treatment

Orthodontics. Part 2: Patient assessment and

Department, Leeds Dental Institute,

This section concentrates on the extra- and

BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 2003

Fig. 2 Shows a patient with a skeletal III pattern

underlying skeletal pattern. Obviously the soft

Conversely, if the head is tipped down the chin

Fig. 3b Malocclusions of the same

BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 2003

There are various ways of measuring the

Fig. 6 Occlusion of the patient

than 50% this can produce an anterior openbite (Fig. 7).

Fig. 8 A centre line

Fig. 9 Teeth are

metry in the facial mid-line. If there appears to

SOFT TISSUE EXAMINATION

the skeletal pattern is unfavourable in either the

BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 2003

need to be corrected with active appliance

TEMPORO-MANDIBULAR JOINT PROBLEMS

Vig P S, Cohen A M. Vertical growth of the lips: a serial

Careful patient assessment is the most important part of treatment

Orthodontics. Part 3: Patient assessment and

1*Consultant Orthodontist, Orthodontic

Department, Leeds Dental Institute,

BRITISH DENTAL JOURNAL VOLUME 195 NO. 10 NOVEMBER 22 2003

tionable dental health should be confined to

Fig. 2 This patient has

molar. Add these together to give you the